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THESIS  ON  THE  CATARACT, 


WITH     SOME     REMARKS     ON 


THE  EYE. 


BY 

ARTHUR  B.    STOUT. 


PRESENTED   TO    THE   FACULTY    OP   THE   COLLEGE    OP   PHYSICIANS   AND   SURGEONS, 
OF   NEW-YORK,    FOR   THE    DEGREE    OF    DOCTOR    OF   MEDICINE. 


April,  1837. 


NEW.YORK: 
PUBLISHED  BY  HENDERSON  GREENE,  435  BROADWAY. 

1  s  :i  7 . 


,ib,    1    Apr.    2  93 


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.596 
It  $7' 


OOIiUMBIANA 


•#»»"-     / 


TO    THE 


FACULTY 


COLLEGE  OF  PHYSICIANS  AND  SURGEONS  OF 
NEW-YORK, 


THESIS  ON   CATARACT 


13  RESPECTFULLY   ADDRESSED 


THEIR.     MUCH     OBLIGED    PUPIL, 


ARTHUR  B.  STOUT. 


This  opportunity  of  expressing  his  gratitude,  esteem,  and 
affection,  to 

Dr.  Edward  Delafield, 
Dr.  John  Kearny  Rodgers,  and 
Dr.  James  Edward  Cornell, 
for  their  constant  kindness,  while  under  their  observation  at  the 
College  and  Hospital,  and  the  many  facilities  for  improvement 
afforded  him  from  their  private  practice,  is  embraced  with 
much  pleasure,  by  their 

Attached  friend, 

ARTHUR  B.  STOUT. 


ON   THE    EYE, 


OPHTHALMIC    SURGERY. 


The  eye  is  the  most  perfect  object  in  Nature  ;  and,  as  per- 
fection and  order  constitute  beauty,  it  is  also  the  most  beautiful. 
Within  the  narrow  limits  of  its  orbit,  may  be  found  illustrated 
nearly  all  the  grand  physiological  phenomena  of  the  animal 
system.  With  the  exception  of  the  functions  of  respiration,  di- 
gestion, and  ideality,  there  are  none,  I  believe,  of  the  great 
processes  of  animal  nature,  which  are  not  discoverable  in  the 
eye  ;  and  manifested  there  in  the  utmost  perfection. 

The  delicacy,  and  minuteness  of  its  anatomy,  are  no  where 
surpassed  in  the  body  ;  and,  with  regard  to  the  globe  of  the 
eye,  its  normal  structure  is  less  frequently  departed  from  than 
in  any  other  organ.  The  distribution  of  its  blood  vessels, 
which  elsewhere  admits  of  variation,  is  always  precise  ;  neither 
are  adventitious  muscles ;  an  unusual  formation  of  bone ;  or 
irregular  position  of  parts,  ever  found  in  this  admirable  and 
wonderful  organization.  The  result  of  such  accuracy  of  ar- 
rangement, is  the  great  perfection  and  harmony  of  its  functions. 
Where  is  the  process  of  secretion  more  completely  elaborated  ? 
the  crystal  dew  is  not  so  transparent  as  the  humors  of  the 
eye.  As  rapid  as  thought  is  its  muscular  motion  ;  and  intense 
as  is  this  action,  the  utmost  skill,  and  care  of  the  artist  cannot 
direct  an  instrument  so  precisely  to  the  point  required,  as  the 


muscles  of  the  eye  adjust  its  position.  The  iris,  which  is  now 
admitted  to  be  muscular,  displays  the  most  astonishing  celerity, 
and  precision  of  motion ;  in  constant  readiness  to  protect  the 
nerve  of  vision  from  the  effect  of  too  much  light,  it  yet  never 
prevents  its  receiving  enough.  Viewed  as  an  instance  of  invol- 
untary muscularity,  it  is  assuredly  the  most  perfect  specimen  in 
the  body.  The  combination  of  power  in  the  external  volun- 
tary muscles  of  the  eye,  is  a  peculiar  endowment  found  in  no 
other  part  of  the  muscular  system.  Though  they  are  usually 
considered,  and  are  in  the  main,  voluntary  muscles,  they  are, 
also,  to  a  certain  extent,  involuntary.  If  the  eye  be  directed  to 
one  object,  to  the  exclusion  of  every  other,  for  a  very  short 
space  of  time,  the  object  becomes  obscure,  and  presently  can- 
not be  seen.  When,  however,  the  slightest  variation  of  the 
eye  admits  the  rays  of  light  from  another  object,  the  former  is 
instantly  seen  with  clearness.  The  sensibility  of  the  eye  seems 
to  require  this  constant  relief.  But  the  will  cannot  be  supposed 
to  take  cognizance  at  all  times,  of  the  time  and  necessity  for 
this  slight  alteration  in  the  direction  of  the  eye  ;  nor  can  the 
motion  be  made  without  the  assistance  of  the  external  mus- 
cles. In  this  respect,  therefore,  their  action  is  involuntary — 
though  they  are  still  constantly  subject  to  the  influence  of  the 
will.  The  endowments  of  the  eye,  attributable  directly,  and 
solely,  to  the  nervous  system,  are  its  sensibility  and  the 
sense  of  vision  ;  and  no  where  in  the  body  is  sensibility  more 
exquisite,  than  in  this  organ.  From  the  facility  with  which  so 
delicate  a  structure  may  be  deranged,  it  has  been  rendered 
by  an  all-provident  Creator  intensely  alive  to  the  least  approach 
of  danger.  In  regard  to  the  sense  of  sight,  what  would  be 
man  exiled  from  intercourse  with  the  natural  objects  which 
surround  him  !  Herein  comparison  with  the  other  senses  is 
impossible,  for  all  are  exquisite  and  perfect.  But  as  it  con- 
tributes essentially  to  the  happiness  of  man,  it  is  certainly 
among  the  most  important  of  the  animal  functions  ;  and  it  is  far 
beyond  comparison  with  any  of  the  known  attributes  of  inani- 
mate nature. 


It  is  curious,  that  nearly  all  the  elementary  tissues  enume- 
rated by  Bichat  may  be  found  in  the  orbital  space ;  affording 
a  study,  on  a  small,  but  perfect  scale,  of  most  of  the  structures 
in  the  animal  economy.  Thus,  the  dermoid  tissue  covers  the 
palpebral  ;  the  adipose,  constitutes  the  soft  cushion  in  the  orbit, 
whereon  the  eye  rests,  and  which  supports  the  ophthalmic  ves- 
sels and  nerves  ;  the  cellular  is  every  where,  but  is  probably 
finer  in  its  texture  between  the  coats  of  the  eye  than  in  any 
other  situation.  The  muscular  is  illustrated  in  the  external 
muscles  of  the  eye,  and  still  more  beautifully  in  the  iris.  The 
sanguineous,  is  found  in  the  ophthalmic  vessels :  and  three  at  least 
of  its  six  terminations,  viz.  into  veins,  by  exhalents,  and  by  inos- 
culation are  here  apparent.  The  lymphatic  system  exists  in 
the  eye,  as  elsewhere ;  and  the  glandular  is  found  in  the  lach- 
rymal and  Meibomian  glands.  The  nervous  system  is  devel- 
oped in  all  its  varieties,  except  that  devoted  to  ideality;  the 
optic,  is  the  nerve  of  sense  ;  the  sympathetic,  or  nerve  of  or- 
ganic life,  pervades  every  part  of  the  system,  and  hence  must 
also  be  here ;  and  the  lenticular  ganglion,  where  a  nerve  of 
sensation  and  one  of  motion  unite,  to  proceed  in  conjunction  to 
the  interior  of  the  eye,  constitutes  another  beautiful  example  of 
the  wisdom  and  design  manifested  in  the  human  frame.  The 
orbit  itself,  displays  the  osseous  system ;  the  conjunctiva,  the 
mucous ;  and  the  serous,  is  developed  in  the  hyaloid  mem- 
brane, and  in  that  of  the  anterior  chamber  of  the  eye.  These 
are  sufficient  examples. 

Another  striking  evidence  that  the  eye  is  the  most  delicately 
formed,  and  highly  perfected  of  the  Creators  works,  is  the  care 
with  which  He  has  guarded  it  from  injury.  Observe  the  situa- 
tion of  the  elaborate  mechanism  of  the  ear ;  deeply  lodged  in 
the  centre  of  the  hardest  of  the  bones,  and  remote  from  the  sur- 
face of  the  body,  it  cannot  be  assailed  by  any  but  the  most 
destructive  and  fatal  violence.  Nor  can  the  anatomist  ap- 
proacfa  it  without  the  greatest  difficulty.  Like  it,  the  eye  is 
nearly  mrroanded  by  bone;  and,  in  front,  where  it  appears 
more  exposed,  it  is  equally  well  protected.     The  palpebral  de- 


10 

fend  it  from  trifling  injuries  ;  while  every  muscle  in  the  body- 
may  be  thrown  into  instantaneous  action  to  guard  it  from  ruder 
assaults. 

Such  are  a  few  of  the  points  of  beauty  in  the  physical  func- 
tions and  structure  of  the  eye.  Did  none  such  exist,  its  en- 
dowments alone  are  sufficient  to  elevate  the  mind  to  the  highest 
degree  of  wonder  and  admiration.  If  the  great  universe  be 
created  on  a  scale  too  comprehensive  for  the  mind  to  embrace, 
and  thus  ascend  from  nature  to  nature's  God,  in  this  small  or- 
gan it  may  range  at  large  ;  and  those  unacquainted  with  the 
construction  of  the  instrument,  have  yet  a  more  ample  scope 
for  their  imagination  in  its  two-fold  endowments.  Its  first,  the 
power  of  vision,  scarcely  surpasses  its  second,  the  power  of  ex- 
pression ;  and  if  it  be  incomprehensible  how  the  image  of  an 
object  on  the  retina  produces  an  idea  of  that  object  in  the  mind, 
we  are  equally  lost  when  we  inquire  into  the  mysterious  faculty 
of  the  eye,  to  embody  and  express  to  another  our  inmost 
thoughts  and  feelings. 

In  the  eye,  the  surgeon  possesses  the  most  interesting  field 
for  practice,  and  also  for  pathological  research.  Anatomy 
and  observation  make  known  to  him  the  precise  normal  condi- 
tion of  the  organ.  He  is,  thereby,  enabled  to  discover  the  least, 
and  earliest  departure  from  it ;  and  thence,  the  origin,  progress, 
and  decline  of  disease  are  delineated,  as  by  a  picture,  to  his 
view.  The  remark  is  true  of  nearly  all  the  structures  of  the 
eye.  As,  however,  disease  in  each  assumes  a  different  form 
according  to  its  organization,  the  surgeon  has  the  enviable  op- 
portunity of  forming  a  perfect  diagnosis  between  them.  In  the 
varieties  of  the  same  disease,  alike  facilities  are  afforded  ;  for,  as 
it  is  viewed  where  it  exists,  and  not  by  remote  symptoms,  the 
slightest  changes  in  form  may  be  noted.  Witness  the  simple 
and  metastatic  iritis.  The  acute  form  of  all  diseases  are  com- 
paratively easy  of  management ;  but  the  atonic,  and  chronic 
forms,  often  baffle  the  most  skilful  and  experienced.  It  is 
here,  the  ophthalmic  surgeon  enjoys  his  greatest  advantage.  He 
has  seldom  to  discriminate  between  the  primary  and  secondary 


11 

affection  ;  and  as  its  pathological  condition  is  not  concealed,  he 
may  observe  the  precise  effect  of  remedial  agents  ;  the  time 
they  prove  of  service  :  and  when  they  cease  to  be  of  benefit. 

The  preservation  of  sight,  is  secondary  only  to  the  preser- 
vation of  life.  Though  the  ophthalmic  surgeon  is  not  denied  the 
fame  derived  from  the  second,  his  reputation  is  chiefly  due  to 
the  first.  And  yet,  so  immediate  and  palpable  is  the  change  he 
may  often  effect  for  his  patient,  translating  him  as  it  were  from 
darkness  to  light,  that  more  eclat  may  accompany  his  career, 
than  often  the  physician  enjoys,  who  preserves  life,  but  whose 
strength  has  been  expended  in  a  hidden  course,  where  neither 
the  intensity  of  disease,  nor  his  skill  could  be  adequately  ap- 
preciated. 

Notwithstanding  its  advantages,  this  beautiful,  and  now, 
highly  perfected  branch  of  surgery  is  in  this  country  neglected. 
In  America,  general  surgery  and  medicine  may  be  deemed  to 
have  attained  as  high  a  rank  as  in  Europe ;  but  in  ophthalmic 
surgery,  Germany  and  England  are  yet  far  in  the  advance.  With 
the  exception  of  a  few  distinguished  persons,  scarcely  any  are 
sufficiently  acquainted  with  the  diseases  of  the  eye  to  have  con- 
fidence in  their  own  knowledge.  In  our  colleges  the  subject  is 
cursorily  glanced  at  in  the  courses  on  general  surgery,  and  the 
student  becomes  too  much  engrossed  in  them  during  his  short 
term  of  study,  to  resort  privately  to  the  imported  books  on 
the  .subject.  From  this  indifference  at  the  fountain  head  of 
learning,  a  general  ignorance  is  allowed  to  exist  throughout  the 
profession.  The  surgeon,  who  while  a  student  received  no  im- 
pulse,  and  was  too  deeply  engrossed  in  general  pathology  to 
commence  alone,  having  retired  to  his  office,  or  the  country, 
finds  in  his  vis  inertia;  a  sufficient  argument  to  prevent  a  prose- 
cution  of  the  study.  In  Germany  and  England,  the  universi- 
ties are  endowed  with  a  distinct  professorship  for  ophthalmic 
surgery,  while  at  Vienna  the  subject  is  divided  into  two 
branches,  viz  :  a  practical  and  genera]  course  of  ophthalmology. 
Of  these,  1 1 » *  -  practical  course  consisted  of  five  lectures 
weekly,  and  was  of  ten  months  duration.    In  all  i best;  places 


12 

numerous  treatises  on  the  eye  have  been  published.  Journals 
devoted  to  ophthalmic  surgery,  are  also  supported  in  the  great 
cities  of  Europe.  The  consequence  of  such  attention  must  be 
a  general  diffusion  of  knowledge :  and  the  student,  if  only  par- 
tially instructed,  has  at  least,  been  far  enough  introduced  to 
estimate  the  beauty,  and  the  value,  of  the  study.  He  is  compe- 
tent to  continue  his  researches  alone  ;  and  soon  enabled  to  con- 
tribute to  the  advancement  of  the  science.  Were  such  efforts 
made  in  our  own  country,  the  same  proficiency  might  be 
effected  in  this  branch,  that  has  been  obtained  in  the  general 
sciences.  Perhaps  no  fact  will  better  illustrate  the  general 
deficiency  of  knowledge  in  ophthalmic  surgery  than  the  records 
of  the  New  York  Eye,  and  Ear  Infirmary.  This  institution 
was  founded  in  1620,  by  Drs.  Delafield  and  Rodgers,  and  until 
the  last  year  has  been  the  only  institution  of  the  kind  in  the  city. 
None  previously  existed.  It  has  possessed  no  means  of  obtain- 
ing notoriety  beyond  the  gradual  diffusion  of  its  name  through 
those  who  had  enjoyed  its  benefits.  Without  a  public  building 
to  command  attention ;  or  a  corporation  to  give  it  eclat,  and 
attract  the  confidence  of  the  public,  it  has  received  between 
one  and  two  thousand  patients  during  the  year.  And  since 
its  foundation  has  afforded  relief  to  seventeen  thousand  persons. 
Another  ophthalmic  institution,  recently  commenced  in  the 
city,  is  already  in  a  flourishing  condition : — and  the  few  surgeons 
who  have  devoted  particular  attention  to  the  eye,  in  their  prac- 
tice constantly  receive  patients,  not  only  from  physicians  in  the 
country,  but  from  those  in  the  city,  who  are  compelled  to  de- 
cline the  cases. 

In  making  these  remarks,  I  presume  not  to  speak  as  one 
acquainted  with  the  subject ;  but  the  neglected  condition  of 
ophthalmic  surgery  must  be  apparent  to  any  who  will  give  it  a 
moment's  attention.  I  speak,  but  as  one  willing  to  commence 
its  study  with  ardor  and  perseverance. 


CATARACT. 


The  one  of  the  many  diseases  of  the  eye,  I  shall  attempt  to 
describe,  is  cataract. 

This  affection  occurs  in  the  crystaline  humor  of  the  eye,  and 
its  investing  membrane.  These  parts  it  is  necessary  to  under- 
stand in  their  normal  state,  and  relations,  before  their  dis- 
eased condition  can  be  properly  described. 

Anatomy. — The  eye  consists  of  three  transparent  substan- 
ces, called  humors ;  a  nervous  expansion,  termed  the  retina ; 
and  certain  membranes,  which  surround  them,  retain  them  in 
their  situation,  and  contribute  to  their  nourishment. 

These  humors  are  named  the  aqueous,  the  crystaline,  and  the 
vitreous.  They  fill  the  eye ;  the  aqueous  being  situated  anteri- 
orly ;  the  crystaline,  in  the  middle  ;  the  vitreous,  posteriorly ; 
and  they  are  held  distinct  by  membranous  septa. 

The  vitreous  humor  occupies  two-thirds  of  the  cavity  of  the 
globe  ;  the  remainder  is  devoted  to  the  aqueous,  and  crystaline 
humors,  with  the  exception  of  the  space  occupied  by  the  iris, 
and  ciliary  processes. 

The  crystaline  humor  is  concerned  in  cataract ;  to  it  there- 
fore I  confine  my  attention.  This  humor,  or  the  lens,  as  it  is 
a~  frequently  termed,  is  situated  in  a  concavity  in  the  centre  of 
the  anterior  surface  of  the  vitreous  humor,  immediately  behind 
the  iri-  and  pupil.  The  canal  of  Petit  surrounds  its  circumfer- 
ence. Though  so  near  the  surface  its  transparency  renders  it 
im  isible. 

The  lens  is  the  most  firm  and  dense  of  the  humors.  It  is 
perfect!}  transparent,  and  possesses  a  high  refractive  power. 
It  measures  about  two  and  a  half  lines  in  thickness,  and  twelve 
or   fourtei  D  in  circumferance.      The  convexity  of  the  anterior 


14 

and  posterior  surfaces  differs  very  considerably ;  the  former 
being  the  segment  of  a  sphere  -about  five  lines  in  diameter, 
while  the  posterior  is  one  from  six  to  nine  in  diameter.  The 
size  of  the  lens,  however,  is  not  constant.  It  varies  much  in 
different  persons,  and  frequently  also,  in  the  two  eyes  of  the 
same  person.  Neither  is  its  form  always  so  perfect  as  it  is  usu- 
ally represented.  The  lens  consists  of  two  portions  ;  an  exter- 
nal softer  part,  called  the  cortical  substance,  and  the  central  por- 
tion, or  nucleus.  This  soft,  gelatinous,  substance  is  arranged,  in 
regular  concentric  layers,  increasing  in  density  as  they  approxi- 
mate the  centre  of  the  lens.  These  may  be  easily  separated 
when  the  lens  is  hardened  by  alcohol,  or  by  boiling.  The  layers 
are  slightly  connected  by  cellular  substance,  and  have  between 
them  a  trace  of  fluid.  The  exterior  of  the  lens  is  bathed  by 
a  fluid,  which  separates  it  from  its  investing  membrane,  and  is 
called,  from  the  name  of  its  discoverer,  the  fluid  of  Morgagni. 

A  distinct  investing  membrane,  called  the  capsule  of  the 
lens,  surrounds  this  body  in  every  part.  This  is  thicker  than  the 
hyaloid  membrane  which  invests  the  vitreous  humor,  and  is 
more  vascular.  It  possesses  a  fibrous  texture.  Owing  to  dif- 
ferent portions  of  it  becoming  opake  in  different  cases,  it  is 
divided  for  the  sake  of  convenience  into  an  anterior  capsule  or 
that  portion  which  covers  the  anterior  convexity  of  the  lens  ; 
and  a  posterior  capsule,  or  the  investment  of  the  posterior  con- 
vexity. There  is,  however,  no  natural  division.  This  capsule 
is  plentifully  supplied  with  blood  ;  but  nerves  have  never  been 
detected  in  its  substance.  The  arteria  centralis  retinae  sup- 
plies the  posterior  portion  ;  and  branches  are  given  off  from 
the  short  ciliary  arteries  which  ramify  upon  its  anterior  surface. 
The  veins  of  the  choroid  coat,  receive  the  blood  from  the  pos- 
terior capsule  ;  but  in  the  anterior  no  veins  have  been  discov- 
ered. It  is  the  capsule  of  the  lens  which  probably  secretes  the 
fluid  of  Morgagni,  for  its  outer  surface  is  connected  by  cellular 
substance  to  the  hyaloid  membrane ;  and  the  canal  of  Petit, 
with  which  it  communicates,  is  always  empty  ;  while  its  inner 
surface  is  smooth  and  soft,  like  that  of  a  secreting  membrane. 


15 

Its  possessing  also  a  free  distribution  of  blood  vessels,  only  a 
a  very  few  of  whose  branches  enter  the  lens,  would  appear  to 
indicate  it  as  a  secreting  membrane. 

The  lens  and  its  capsule,  are  retained  in  their  proper  situa- 
tion by  the  hyaloid  membrane.  This  membrane,  after  covering 
the  posterior  portion  of  the  vitreous  humor,  arrives  at  the  cir- 
cumference of  its  anterior  surface.  It  here  turns  upon  the 
anterior  part  of  the  vitreous  humor,  and  lies  beneath  the 
ciliary  processes,  where  from  some  peculiarities  it  possesses,  itais 
called  the  zonula  of  Zinn.  At  the  apices  of  these  processes,  the 
hyaloid  divides  into  two  layers,  each  of  which  is,  however,  as 
firm  as  the  single  membrane.  One  layer  now  passes  behind 
the  lens  and  capsule,  closely  attached  to  the  vitreous  humor, 
and  also  adherent  to  the  capsule  of  the  lens.  The  other 
passes  over  the  anterior  surface  of  the  capsule,  forming  a  close 
connexion  with  it.  It  is  bathed  in  front  by  the  aqueous  humor. 
By  this  division,  a  small  space  is  left  between  it  and  the  cir- 
cumference of  the  capsule  of  the  lens.  This  was  first  detected 
by  M.  Petit,  and  after  him,  is  called  the  canal  of  Petit.  It  does 
not  contain  a  fluid.  These  membranes,  like  the  humors  they 
inclose,  possess  the  most  perfect  transparency. 

Definition. — Cataract  is  an  opacity,  either  partial  or  com- 
plete, of  the  crystaline  humor  of  the  eye  ;  of  its  capsule ;  or 
of  both  conjointly. 

It  is  usual  to  include  in  the  definition  of  cataract,  an  opa- 
ity  of  the  fluid  of  Morgagni ;  but  as  this  fluid  exists  in  an 
extremely  small  quantity  ;  and  is  so  situated  that  its  discoloration 
alone  cannot  be  recognised,  I  prefer  to  omit  it.  Indeed  any 
opacity  of  this  fluid,  per  se,  is  doubted ;  or  if  it  could  exist,  the 
disease  would  probably  have  extended  to  the  lens  or  capsule 
before  any  d<rangement  of  the  eye  was  suspected.  Again,  the 
fluid  of  Morgagni  must  bo  a  secretion,  either  from  the  lens,  or 
capsule,  probably  from  the  latter,  and  consequently  could  not 
become  altered  in  <lmraeter,  without  previous  disorder  of  its 
secreting  .surface.     It  would  not  be  more  refined  to  indicate  as 


16 

a  division  of  the  disease,  opacity  of  the  hyaloid  membrane 
which  covers  the  capsule,  than  to  designate  as  a  separate  affec- 
tion, that  of  the  fluid  it  contains. 

Mr.  Lawrence,  in  his  recent  work  on  the  eye,  adds  to  the 
definition  of  cataract,"  opacity"  &c,  "  with  corresponding  dimi- 
nution of  sight."  The  loss  of  sight,  however,  is  but  an  effect  of 
the  disease.  It  is  a  consequence  of  the  exclusion  of  light,  and 
is  not  a  part  of  the  disordered  action  which  constitutes  the 
affection.  If  it  be  proper,  to  add  one  of  its  effects  or  symptoms 
to  the  definition  of  the  disease,  it  must  also  be  necessary  to 
include  them  all,  and  hence  if  "  diminution  of  sight"  be  neces- 
sary to  the  definition,  the  difficulty  of  walking  alone,  or  the 
white  pupil  apparent  to  the  observer  of  the  eye,  would  be  of 
equal  importance  to  its  completeness.  Conciseness  is  the 
chief  requisite  of  a  definition ;  and  when  the  pathological  con- 
dition of  the  disease  is  known,  it  is  immediately  derived  there- 
from. Symptoms  are  only  resorted  to  when  this  condition  is 
not  ascertained.  In  cataract  it  has  been  but  partially  discov- 
ered, and  surgeons  therefore  define  the  disease  "  opacity"  &c. ; 
but  if  it  were  proved  to  consist  always  in  an  imflammatory  ac- 
tion the  definition  would  simply  be,  inflammation  of  the  lens,  &c. 
For  these  reasons  I  have  restricted  my  definition  to  a  statement 
of  the  parts  involved  in  disease,  and  of  that  principal  change 
without  which  the  affection  cannot  exist. 

Derivation. — The  name  cataract  is  derived  from  the  Greek 
word  catarasso,  to  confound  or  disturb,  because  the  disease  in- 
terferes with  vision. 

Divisions. — The  number  of  circumstances  under  which 
cataract  occurs  has  given  rise  to  a  variety  of  classifications, 
These  have  been  founded  upon  the  relative  importance  which 
authors  attached  to  certain  features  of  the  disease.  An  arrange- 
ment which  would  early  suggest  itself  is  that  of  the  simple 
form,  when  only  the  lens  and  capsule  are  implicated,  and  the 
complicated  where  it  takes  part  with  some  more  general  affec- 
tion.    This  method  has  been  superseded.     The  term  spurious 


17 

cataract  was  introduced  by  the  celebrated  Beer,  of  Vienna, 
and  applied  to  matters  effused  in  the  posterior  chamber,  before 
the  lens,  so  as  to  resemble  cataract.  But  this  term  is  discarded, 
as  whatever  is  not  an  opacity  of  the  lens  or  capsule  is  not  cat- 
aract at  all.  Another  division  is  that  of  mature  and  immature 
cataract,  signifying  that  the  opacity  has,  or  has  not,  proceeded 
to  its  utmost  extent.  This  is  of  no  other  importance  than  that 
it  shows  the  existence  of  two  such  states. 

A  classification,  which  is  much  more  interesting,  as  it  gives 
an  idea  of  the  origin  of  the  disease,  consists  of  four  varieties, 
the  spontaneous,  the  sympathetic,  the  traumatic,  and  the  con- 
genital cataracts.  The  first  arises  without  any  known  cause 
and  is  also  called  idiopathic.  The  second  occurs  in  company 
with  other  deep-seated  affections  of  the  globe ;  the  third  is  the 
result  of  injuries  by  external  violence,  and  the  fourth  is  found 
at,  or  before,  the  time  of  birth.  As  all  these  varieties  have 
marked  peculiarities,  and  require  corresponding  variations  in 
their  treatment,  the  arrangement  is  one  of  value  and  impor- 
tance. The  division  of  cataract,  according  to  the  situation 
of  the  opacity  with  regard  to  the  lens  or  capsule,  is  the  most  in 
accordance  with  the  present  natural  system  of  nomenclature, 
that  of  naming  a  disease  according  to  its  pathological  condition  ; 
and  dividing  it,  according  to  the  tissues  in  which  it  occurs. 
Hence,  the  classification  of  cataract  into  1st,  capsular ;  2d,  len- 
ticular ;  and  3d,  capsulo-lenticular — as  it  affects  the  capsule,  the 
lens,  or  both  together,  is  that  now  generally  received.  It  is  the 
more  important,  as  it  is  of  the  greatest  consequence  in  practice. 
The  capsular,  and  lenticular  cataracts  have  each  several  spe- 
cies, which  I  refer  to  their  respective  heads. 

Description. — When  an  eye  which  contains  a  simple,  ma- 
tun:  cataract  is  examined,  the  first  appearance  which  attracts 
the  attention,  is  a  white,  or  yellowish  white  spot,  occupying  the 
pupil,  and  intercepting  toagreateror  less  extent  the  passage  of 
light  to  the  retina.  In  every  other  respect,  the  eye  appears 
natural;  there  is  no  increase  of  vascularity  in  the  external 
tunics  ;  the  iris  possi  jes  its  proper  form  and  action  ;  n<>  pain  is 


18 

experienced,  and  the  only  complaint  of  the  patient  is  his  loss 
of  sight.     This  white  spot  is  found,  on  closer  inspection,  to  be 
situated  immediately  behind  the  iris  ;  and  is  the  opaque  lens  and 
capsule.     That  it  is  in  no  other  situation,  is  immediately  proved 
by  looking  at  the  eye  obliquely,  by  which  means,  any  opacity 
of  the  cornea  will  be  detected,  the  corneal  opacity  being  then 
seen  quite  superficial,  and  preventing  a  distinct  view  of  the  iris 
opposite  the  side  examined.     It  is  no  deeper,  for  the  vision  of 
the  observer  is  arrested  at  the  pupil.     This  opacity  does  not 
entirely  prevent  vision.     It  will  be  found  that  the  patient  can 
distinguish  light  from  darkness  ;  perhaps  can  point  to  the  win- 
dow, and  if  the  fingers  be  passed  before  his  eye  while  so  doing, 
will  perceive  that  something  dark  has  moved  before  him.     In 
general,  he  will  only  distinguish  light,  the  amount  of  which  he 
can  perceive  depending  upon  the  density  of  the  cataract  and 
the  dilatation  of  the  pupil.     The  state  of  the  pupil  is  of  great 
importance  in  the  examination  of  a  cataract,  for  however  great 
the  opacity,  some  rays  still  penetrate  it,  and  consequently  the 
greater  the  space  for  their  admission  the  more  the  patient  can 
perceive.     Some   useful  experiments  may  by  this  means   be 
made  to  prove  its  existence.     If  the  patient  be  turned  from 
the  light,  the  pupil  enlarges  to  admit  a  greater  number  of  rays, 
and  he  perceives  more  light  than  when  he  looks  in  the  direction 
whence  it  comes.      For  the  same  reason,  he  will  see  better 
towards  evening,  than  by  mid-day.  Artificial  dilatation  of  the  pu- 
pil may  be  effected  by  means  of  the  stramonium,  or  belladonna, 
and  this  may  be  done  to  such  a  degree  that  the  patient  sees  with 
comparative  distinctness.     In  some  cases  it  obviates  the  neces- 
sity of  more  radical  treatment.     The  perception  of  more  light 
after  its  use,  is  always  evidence  that  the  opacity  is  a  cataract. 
With  the  exception  of  this  variation  of  sight  from  the  contrac- 
tion of  the  iris,  the  condition  of  vision  is  always  constant ;  and 
its   diminution   in    the   progress    of   the   disease    equally  so, 
depending   solely    upon   the   increase    of  opacity.      Such   is 
cataract  in  its  simple  state. 

The  first  indication  of  its  commencement  is  a  cloudiness,  or 


19 

mist  observed  before  the  eye,  and  obscuring  vision.  When  at 
this  early  period,  the  eye  is  examined,  a  slight,  diffused  haziness 
may  be  observed  behind  the  iris ;  having  a  bluish  white  ap- 
pearance. If  now  the  patient  look  at  a  candle,  it  appears  dim> 
and  has  a  halo  around  the  flame.  This  halo,  in  cataract,  is  al- 
ways the  same,  being  only  an  appearance  of  the  radiation  of 
light  from  the  candle.  From  this  time,  the  diminution  of  sight 
continues  gradually,  and  regularly,  to  increase  ;  and  the  nebula 
perceptible  in  the  eye,  becomes  more  white  and  dense  until  the 
cataract  is  fully  formed.  The  duration  of  the  process  is  ex- 
tremely variable.  A  perfect  cataract  may  be  formed  in  three 
days,  or  the  patient  may  be  conscious  of  a  gradual  diminu- 
tion of  sight  for  several  years.  Neither  are  both  eyes  simulta- 
neously affected  ;  one  eye  may  remain  always  sound :  and  when 
both  are  the  subject  of  disease,  the  affection  in  the  one  gene- 
rally commences  when  the  cataract  in  the  other  is  quite  or  nearly 
mature.  The  progress  of  the  disease  is  frequently  so  mild,  and 
gradual  that  the  patient  is  unconscious  of  a  diminution  of  sight 
in  the  affected  organ,  until  told  that  something  is  growing  in  his 
eye,  he  is  induced  to  close  the  healthy  eye  in  order  to  detect  it. 
It  is  not,  however,  invariably  so.  The  disease  is  sometimes 
ushered  in  with  acute  inflammation.  In  this  case  it  is  accom- 
panied with  iritis.  The  patient  is  conscious  of  some  pain  and 
fulness  in  the  eye  ;  sometimes  there  is  pain  in  the  head  ;  the 
pupil  is  sluggish  ;  the  vessels  of  the  sclerotic  are  enlarged  where 
they  penetrate  that  coat  near  the  cornea,  and  the  white  zone, 
which  occurs  around  the  cornea  in  iritis,  may  be  seen.  The 
mist  is  now  observed  before  the  eye,  and  increases  rapidly  in 
density. 

Mr.  Stratford,  of  the  London  Dispensary  for  diseases  of  the 
eye,  states  that  if  the  organ  be  now  examined  with  a  magnify- 
ing glass,  vessels  may  be  seen  ramifying  on  the  anterior  capsule, 
forming  :i  perfect  network,  and  depositing  fibrin  either  in  its 
centre,  or  along  their  course.  If  the  disease  be  checked  by 
active  treatment,  it  may  Bubside,  leaving  the  capsule  in  this 
Htate ;  or  the  severity  of  the  symptoms  may  abate,  and  a  slow 


20 

deposition  of  fibrin  take  place  until  a  perfectly  opaque  cataract 
be  formed.  This  leads  me  to  the  variety  of  appearances  which 
the  cataract  may  assume,  depending  upon  the  manner  in  which 
fibrin  is  deposited,  either  in  the  lens  or  capsule  ;  and  also,  upon 
the  duration  of  the  disease.  The  opacity  may  exist  in  the  cap- 
sule, in  the  lens,  or  in  both ;  constituting  the  division  into  capsu- 
lar, lenticular,  and  capsulo-lenticular.  In  each  of  these  situations, 
its  appearance  is  modified.  The  cataract  also  differs  in  density 
and  this  circumstance  also  affects  its  appearance.  These  states 
it  is  necessary  carefully  to  discriminate,  as  the  treatment  of  the 
disease  depends  upon  them. 

Capsular  Cataract. — Disease  of  the  capsule,  in  general,  soon 
affects  the  lens,  and  consequently  the  capsulo-lenticular  variety 
is  the  most  common.  Still,  opacity  of  this  part  may  exist  alone. 
It  may  also  be  confined  to  the  anterior  capsule,  or  the  posterior ; 
the  cataract  being  then  named  in  accordance,  anterior  capsular, 
or  posterior  capsular.  Sometimes  both  portions  are  involved  ; 
and  the  term  complete  capsular  is  then  applied  to  the  cataract. 
The  opacity  of  the  lens  and  capsule  is  owing  to  the  deposition 
in  their  texture  of  white  fibrin  from  vessels  which  naturally 
convey  and  secrete  a  colorless  fluid.  The  vessels  of  the  capsule 
ramify  freely  on  its  surface,  some  forming  inosculations,  and 
some  terminating  in  exhalents.  In  disease,  fibrin  is  poured  out 
more  abundantly  by  some  than  by  others,  and  sometimes  is  de- 
posited in  the  centre  of  the  capsule,  and  at  others  near  its  cir- 
cumference ;  again,  it  may  thus  become  arranged  in  striae,  in 
spots,  in  angular  figures,  or  like  the  veins  of  marble.  This  gives 
rise  to  the  various  species  of  capsular  cataracts  which  are  enu- 
merated by  authors.  There  is  the  cataracta  marmoracea,  or 
variegata,  in  which  the  lines  on  the  capsule  run  in  a  variegated 
manner — the  c.  punctata  or  stellata,  or  mottled  deposition — 
c.  fenestrata,  where  the  lines  are  like  the  bars  of  a  window — 
c.  striata,  or  streaked — c.  dimidiata,  in  which  one  half  the 
capsule  is  opaque — c.  trdbecularis,  where  a  single  thick  bar 
extends  across  the  capsule — and  c.  centralis,  where  a  white  spot 
is  seen  directly  in  the  centre  of  the  capsule.     Various  changes 


21 

which  the  cataract  undergoes  in  the  course  of  disease,  has  also 
given  rise  to  other  species.  Hence  the  c.  pyramidalis,  in  which 
a  dense  mass  projects  into  the  pupil.  The  c.  arida  siliquata, 
or  dry-shelled  cataract,  in  which  the  lens  having  been  absorbed, 
the  two  capsules  come  in  contact,  and  present  a  thickened  and 
shrivelled  appearance.  Sometimes  by  this  means  the  capsule 
becomes  separated  from  its  adhesions,  and  may  be  observed  to 
tremble  ;  tins  is  the  c.  tremula  :  occasionally  it  slips  through 
the  pupil,  and  moves  about  in  the  aqueous  humor ;  and  is  then 
called  c.  natatilis,  or  floating.  The  c.  gijpsea  consists  of  a 
change  of  the  capsule  into  a  cretaceous  yellowish  shell.  In  the 
progress  of  disease,  the  cataract  sometimes  comes  in  contact 
with  the  iris ;  and  after  a  period  of  time  again  retires,  but  car- 
ries with  it  some  of  the  coloring  matter  from  the  uvea  which 
gives  it  a  brown  appearance.  This  variety  is  called  c.  choroi- 
dalis. 

In  the  early  stage  of  anterior  capsular  cataract,  it  may  be 
distinguished  from  lenticular  cataract  by  the  striated  appearance 
of  the  opacity,  and  the  transparent  spaces  between  the  striae. 
The  opacity  usually  begins  at  the  circumference  of  the  capsule 
and  runs  in  shining,  glistening  streaks,  towards  the  centre. 
Their  color  is  nearly  white,  and  becomes  more  apparent  when 
the  iris  is  contracted  by  stramonium.  When  the  capsule  is  en- 
tirely opaque,  the  appearance  is  dull.  The  cataract  approaches 
the  iris  so  closely  as  to  obliterate  the  posterior  chamber,  and 
appears  directly  in  the  pupil.  Sometimes  the  iris  is  pressed 
forward.  As  the  lens  is  generally  at  the  same  time  cataractous, 
it  may  be  seen  through  the  capsule  of  a  different  color.  The 
membrane  is  usually  thickened,  and  hence  the  cataract  appears 
full  and  large. 

Posterior  capsular  cataract  may  be  recognised  from  the 
former,  by  the  evidenl  deep  situation  of  the  opacity.  The  ne- 
bula, though  probably  striated,  has  not  the  bright  glistening 
appearance  it  pos»  wes  when  situated  anteriorly.  The  action 
of  the  iria  u  perfectly  free,  and  the  posterior  chamber,  or  a  space. 
behind  the  iris,  may  be  recognised.    The  opacity  is  dim, deeply 


22 

situated,  and  has  a  bluish  white  appearance.  It  often  happens 
that  a  patient  complains  of  imperfect  vision,  but  on  looking  into 
the  eye  no  opacity  can  be  discovered.  When,  however,  artifi- 
cial dilatation  is  employed,  some  faint  spots,  or  striae  are  disco- 
vered near  the  outer  margin  of  the  capsule.  If  deep  seated, 
they  appear  dim,  and  however  faint,  sufficiently  account  for  the 
loss  of  sight.  The  gradual  manner  in  which  the  opaque  spot  is 
shaded  towards  its  edges  until  it  blends  with  the  transparent 
capsule,  renders  it  impossible  to  judge  how  far  the  nebula  ex- 
tends ;  and  the  shading  makes  the  central  spot  appear  less  deep 
than  it  actually  is.  The  posterior,  like  the  anterior  capsular 
cataract,  seldom  continues  long  without  involving  the  lens. 

Lenticular  Cataract. — This  variety  differs  from  the  capsu- 
lar in  color,  in  density,  in  depth,  and  in  size.  It  is  that  form  to 
which  the  old  are  subject,  and  that,  likewise,  which  constitutes 
the  congenital  cataract.  Both  senile  and  congenital,  may  also 
include  the  capsular  opacity.  Lenticular  cataract  is  generally 
gradual  in  its  formation.  The  opacity  commences  in  the  centre 
of  the  lens :  and,  early  in  the  disease,  the  use  of  stramonium  to 
dilate  the  pupil,  almost  entirely  restores  the  sight.  The  deposi- 
tion of  fibrin  taking  place  in  the  centre  or  nucleus  of  the  lens, 
increases  its  density,  and  as  it  gradually  extends  towards  the 
surface,  the  several  layers  are  rendered  harder  than  natural. 
The  cataract  thus  formed  is  small,  compact,  and  hard.  It  is 
distinguished  by  an  amber,  or  yellow  color,  and  appears  deeply 
situated.  An  evident  space  exists  between  the  iris  and  the 
opaque  spot.  A  black  ring  is  often  seen  around  the  pupil,  which 
is  differently  accounted  for.  It  is  most  frequent  in  blue  eyes. 
Some  authors  consider  it  an  eversion  of  the  margin  of  the  iris, 
by  which  the  uvea  becomes  visible  in  consequence  of  pressure. 
Others  state  that  a  black  ring  always  exists  around  the  inner 
margin  of  the  iris,  but  is  not  observed  on  account  of  the  black- 
ness of  the  pupil.  When,  however,  a  cataract  is  formed,  the 
white  ground  behind  the  iris  brings  the  ring  in  view.  If  now 
the  pupil  be  dilated  by  stramonium  or  belladonna,  the  depth  of 
opacity,  and  the  amber  color  diminish  towards  the  circumference, 


23 

owing  to  the  lens  being  there  thinner  than  at  the  centre.  This 
is  a  useful  diagnostic  in  distinguishing  lenticular  and  capsular 
cataracts.  The  lens  in  this  state  is  without  vitality,  it  therefore 
soon  acts  upon  the  capsule  as  a  foreign  body,  and  creates  irri- 
tation, or  inflammation,  with  consequent  opacity.  It  is  thus  very 
rarely  that  cataract  remains  confined  to  the  part  in  which  it 
originates.  Lenticular  cataracts  are  not  always  firm  in  con- 
sistence. They  are  frequently  soft  or  fluid ;  and  in  different 
cases  vary  considerably  in  their  degree  of  fluidity  or  hardness. 
This  circumstance  has  occasioned  a  division  of  them  into  several 
species.  These  are  cataracta  dura,  or  tenax — c.  Jluida — 
c.  caseosa,  in  which  it  has  the  consistence  of  cheese,  and 
c.  gelatinosa,  that  of  jelly.  The  c.  jiuido-dura  is  that  in  which 
the  nucleus  of  the  cataract  is  hard,  while  the  external  portion  is 
soft.  An  exception  to  the  usual  nature  of  lenticular  cataract 
sometimes  occurs  in  the  c.  radiata.  In  this  variety,  radii  or 
striae  are  seen  shooting  in  every  direction  from  the  centre  of 
the  lens  to  the  circumference.  They  are  sometimes  most  appa- 
rent at  the  centre ;  and  at  others,  only  perceptible  when  the 
pupil  is  dilated  by  stramonium.  The  completion  of  this  form 
usually  occupies  several  years. 

The  congenital  cataract  comes  to  maturity  more  rapidly, 
and  hence  does  not  allow  the  humor  to  become  so  hard,  and 
firm,  as  in  the  affection  of  the  old.  The  cataract  remains  soft, 
and  never  acquires  a  deep  amber  color.  It  appears  large,  is  of 
a  bluish  white  color;  and  is  without  stria?  or  spots.  The  trans- 
parent membrane  investing  it,  produces  a  smooth  polished  sur- 
I  i<  .  The  general  aspect  of  the  cataract  is  nebulous.  The 
opacity  is  deeper  in  some  places  than  in  others,  but  is  diffused, 
and  without  any  transparent  space  between  the  denser  parts. 
The  cataract  is  sometimes  so  soft,  that  it  is  flocculent,  and  if  the 
eye  can  be  kept  perfectly  quiet  for  a  few  moments  the  denser 
flocculi  subside.  The  congenital  cataract  appears  to  have  a 
more  rapid,  and  definite  course  than  any  other  variety.  The 
lens  by  -"iir  meane  become  detached  from  the  capsule,  and 
thus  losing  its  Bource  of  nourishment,  dies.     It  then  acts  as  a 


24 

foreign  substance,  irritating  the  capsule,  and  producing  an  in- 
creased secretion  of  the  Morgagnian  fluid.  This  fluid,  in  its 
turn,  reacts  on  the  lens  and  dissolves  it,  or  promotes  its  absorp- 
tion. At  the  same  time  the  irritation  produced  in  the  capsule 
renders  it,  likewise,  opaque.  The  cataract,  enlarged  by  the  in- 
creased secretion  and  by  the  thickening  of  the  capsule,  presses 
forward  the  iris,  and  appears  to  project  into  the  anterior  cham- 
ber. At  this  time  a  change  takes  place,  the  solution  of  the  lens 
is  finished,  and  the  fluid  begins  to  be  removed  by  absorption. 
The  cataract  retires,  and  diminishes  in  size,  the  iris  regaining  its 
natural  situation.  As  absorption  proceeds,  the  capsule  contracts 
and  shrivels  until  at  the  end  of  the  process  it  remains  a  mere 
membrane.  It  may  by  contraction  be  separated  from  the  ci- 
liary processes ;  and  a  dark  ring  is  then  sometimes  observed 
around  it,  owing  to  the  choroid  membrane  being  visible  through 
the  space.  A  trembling  or  vascillating  motion  of  the  iris  is  in 
such  a  case  occasionally  observed,  attributed  by  Mr.  Stratford 
to  the  loss  of  support  suffered  by  the  iris  from  the  absorption  of 
the  contents  of  the  capsule. 

Capsulo-lenticular  cataract.  This  is  the  common  form  in 
which  cataraet  usually  exists.  It  is  recognised  by  its  large  size  ; 
its  position  immediately  behind  the  iris,  obliterating  the  posterior 
chamber ;  and  by  its  mixed  color.  The  cataract  appears  to  oc- 
cupy the  pupil ;  sometimes  it  encroaches  upon  the  iris,  projects 
it  forward,  and  causes  its  partial  contraction.  When  the  iris  is 
artificially  contracted  under  such  circumstances,  it  relaxes  again 
very  slowly,  and  with  difficulty.  The  thickness  of  the  opaque 
substance  renders  the  transmission  of  light  so  difficult,  that  the 
patient  scarcely  recognises  it.  In  its  color  may  be  discovered 
that  of  the  preceding  varieties  in  their  separate  state,  viz.  a  su- 
perficial white,  cloudy,  or  radiated  appearance,  like  mother  of 
pearl ;  and  a  deeper  yellowish  or  greyish  tint,  sometimes  ap- 
proaching to  an  amber  color,  which  is  the  opaque  lens.  The 
color  of  these  cataracts,  however,  is  liable  to  great  variation.  It 
may  consist  entirely  of  a  bluish  white,  or  light  grey  color ;  or 
in  some  cases  may  be  of  a  deep  brown.     Mr.  Lawrence  states 


25 

that  he  has  never  seen  a  cataract  of  a  deeper  color  than  that  of 
mahogany,  but  in  the  German  authors  black  cataracts  are  de- 
scribed. The  brown  variety  is  very  rare,  and  indicates  great 
hardness  of  the  lens.  The  nearer  the  color  approaches  a  milky 
white,  the  softer  the  cataract  may  be  considered.  It  will  be 
difficult,  however,  to  form  a  diagnosis  of  these  varieties  from 
mere  description.  They  require  great  minuteness  of  observa- 
tion and  a  well-tried  experience.  The  only  advantage  of  the 
diagnosis  is  the  variation  of  treatment  to  which  it  leads. 

Traumatic  cataract  is  an  interesting  variety  of  the  affections 
of  the  lens  and  capsule.  Its  marked  peculiarities  render  it  wor- 
thy of  separate  notice.  These  are  its  rapid  formation  with  acute 
inflammation  ;  its  occasional  spontaneous  disappearance  ;  its  dis- 
location in  many  instances  to  various  parts  of  the  eye ;  the  irri- 
tation and  inflammation  it  occasions  in  such  situations ;  and  the 
nature  of  the  treatment  required  for  its  cure.  Traumatic  cata- 
ract may  originate  in  two  modes  ;  from  an  injury  which  produces 
concussion  of  the  globe,  without  laceration  of  its  textures ;  and, 
secondly,  by  a  penetrating  wound  of  the  globe  in  which  the 
capsule  or  lens  is  ruptured.  The  former,  or  cataract  from  con- 
cussion, may  ensue  from  a  blow  received  on  the  forehead,  or 
over  the  eye ;  or  from  a  blunt  instrument  being  thrust  against 
the  ball.  It  has  been  known  to  arise  from  a  spent  shot  which 
has  struck  the  eye  without  penetrating  its  coats.  Unless  the 
injury  has  been  very  severe,  producing  general  inflammation, 
glaucoma,  or  amaurosis,  the  cataract  seldom  forms  immediately. 
After  the  lapse  of  several  days,  or  perhaps  weeks,  the  person 
begins  to  experience  some  uneasiness  about  the  eye,  as  slight 
pain,  or  sense  of  fulness  and  distention,  and  also  complains  of 
I  obscurely  as  through  a  mist.  If  the  eye  be  now  exam- 
ined,  the  commencing  opacity  will  be  discovered,  which  pro- 
wit  h  greater  or  less  rapidity,  and  with  its  usual  symptoms, 
to  the  formation  <>l'a  perfect  cataract.  Sometimes  the  iris  par- 
tie, pates  in  the  disease,  and  appears  thickened  and  sluggish;  or 
it  may  contract  and  adhere  to  the  capsule.  The  symptoms  are 
ionallym  re,  and  their  progress  more  rapid.    The 


26 

lens  and  capsule  may  be  involved  in  disease  with  the  other  tex- 
tures, and*  from  the  severity  of  the  concussion,  the  capsule  may 
be  ruptured,  the  lens  be  dislodged,  and  falling  into  the  anterior 
or  posterior  chamber,  prove  a  new  source  of  irritation.  Mr. 
Travers  mentions  a  case  in  which  suppuration  took  place  within 
the  capsule  after  an  injury  without  laceration,  but  accompanied 
with  much  acute  inflammation.  A  globular  cataract  projected  the 
iris  against  the  cornea,  and  evidently  consisted  of  the  lens  in- 
volved in  purulent  matter.  After  a  time  both  lens  and  pus 
were  absorbed  by  the  use  of  mercurials,  and  only  a  capsular 
cataract  remained. 

There  are  a  variety  of  displacements  to  which  the  lens 
is  liable  when  dislocated  from  its  capsule,  either  by  the  im- 
mediate concussion,  or  in  consequence  of  the  supervening  inflam- 
mation. Thus  it  may  fall  into  the  posterior  chamber,  and  be 
partially  concealed  from  view.  It  usually,  however,  slips  through 
the  pupil  and  occupies  the  anterior  chamber.  The  lens  has 
been  known  to  enter  the  anterior  chamber  transparent,  and 
remain  there  in  that  state  for  a  length  of  time.  In  general  it  is 
opaque,  and  acting  on  the  delicate  iris  as  a  foreign  body,  pro- 
duces iritis.  Sometimes  the  lens  remains  in  the  anterior  cham- 
ber without  causing  inflammation,  and  is  finally  absorbed. 
Though  a  capsular  cataract  commonly  remains  after  such  cases, 
it  is  now  and  then  absorbed,  and  vision  is  recovered.  In- 
stead of  passing  into  the  anterior  chamber,  the  lens  may  come 
in  contact  with  the  iris  and  thrust  it  forward  against  the  cornea. 
This  case  always  produces  severe  iritis,  and  general  internal 
inflammation  ;  and  demands  the  immediate  removal  of  the  lens 
by  a  surgical  operation.  Again,  the  rupture  of  the  capsule  may 
not  occur  until  disorganization  have  taken  place  in  the  vitreous 
humor,  when  the  lens  may  fall  backward,  sink  out  of  the  axis 
of  vision,  and  be  absorbed.  The  sight  of  the  patient  is  some- 
times restored,  but  in  general,  it  is  destroyed  by  the  existing  glau- 
coma. Mr.  Mackenzie,  from  a  number  of  whose  cases  in  the 
Medical  Gazette,  vol.  9,  page  3,  I  have  collected  these  varieties, 
states  that  by  some  injury,  probably  a  lacerating  one,  the  lens 


27 

has  got  through  the  choroid  and  sclerotic  coat,  and  has  been 
discovered  under  the  conjunctiva. 

2.  The  traumatic  cataract,  from  direct  injury  of  the  capsule 
and  lens,  is  formed  immediately  on  the  receipt  of  the  wound. 
It  is  not  always  accompanied  with  acute  symptoms,  but  these 
parts  cannot  be  wounded  without  opacity  being  the  result. 
Generally  violent  inflammation  is  the  immediate  effect.  The 
wound  may  pass  through  the  cornea,  or  the  sclerotic  coat,  and 
is  generally  made  by  some  pointed  instrument.  Frequently 
bits  of  iron  or  stone,  which  fly  in  cutting  these  materials,  strike 
the  cornea,  where  they  are  commonly  arrested  ;  but  they 
sometimes  penetrate  it  and  enter  the  capsule  either  through  the 
pupil  or  through  the  iris.  A  speck  of  iron  has  thus  been  driven 
into  the  capsule  and  remained  there  without  occasioning  in- 
convenience until  a  capsular  cataract  was  formed.  In  general, 
immediate  and  violent  inflammation  ensues,  accompanied  with 
symptomatic  fever,  and  requiring  the  most  active  depletory 
treatment.  Suppuration  of  the  lens,  with  general  inflammation 
of  the  internal  tunics  follows,  and  if  the  foreign  matter  be  not 
removed,  causes  rupture  of  the  globe  and  discharge  of  its  con- 
tents. Sometimes  the  substance  may  be  seen  and  be  removed 
by  an  operation.  The  inflammation  then  subsides  ;  the  sequel 
of  the  case  depending  upon  the  extent  of  its  ravages. 

Secondary  cataract  is  the  only  variety  remaining  to  be  ob- 
served. The  term  is  applied  to  those  cases  which  occur  after 
operations.  In  the  formation  of  an  artificial  pupil  in  the  iris, 
the  capsule  may  be  cut,  and  the  consequent  cataract  is  called 
secondary.  But  it  is  usually  the  result  of  the  operation,  called 
couching,  in  which  the  lens  is  removed  from  its  situation 
but  the  capsule  remains.  It  becomes  opaque  and  requires  a 
second  operation  for  its  removal.  The  symptoms  and  appear- 
ances of  these  are  the  same  as  the  cases  already  described. 

Complications. — The  cataract  does  not  always  exist  in  this 
simple  and  isolated  sf;it<\  It  is  often  complicated  with  other 
affections.  Glaucoma  and  amaurosis  are'  its  frequent  concomi- 
tants ;  though  the  cataract  is  generally  formed  subsequent  to  the 


28 

existence  of  the  former  diseases.  Often,  the  iris  is  found  adhe- 
rent to  the  lens.  This  may  exist  to  a  sufficient  extent  to  prevent 
any  operation  for  the  removal  of  the  cataract,  though  in  gene- 
ral, it  is  only  attached  at  particular  points.  Sometimes  these 
attachments  are  separated,  when  stramonium  is  applied  to  cause 
contraction  of  the  iris,  and  the  case  is  then  rendered  simple. 
A  case  is  reported  by  Mr.  Travers,  Med.  Gaz.  vol.  v.  p.  67  J ,  in 
which  the  cataract  was  projected  forwards,  and  had  formed  an 
adhesion  to  the  cornea.  There  is  now  at  the  N.  Y.  Eye  Infirmary 
an  interesting  case  of  cataract,  with  extensive  adhesions  of  the  iris ; 
excessively  irregular  pupil,  though  it  dilates  by  the  application  of 
stramonium  ;  and  opacity  of  the  cornea.  The  case  is  render- 
ed more  unusual  by  its  occurrence  in  a  very  young  boy,  after 
severe  iritis  and  ophthalmia.  The  cataract  is  capsular  and  im- 
perfect, there  being  three  circumscribed  and  distinct  specks  on  the 
capsule  which  are  white  and  glistening,  forming  a  strong  con- 
trast with  the  dim  and  cloudy  corneal  opacity.  There  is  also 
a  dark  brown  deposition  which  is  a  portion  of  the  uvea.  The 
treatment  of  the  case  is  directed  to  remove  the  corneal  opacity. 
The  management  of  complicated  cases  is  always  difficult.  In 
cataract  with  glaucoma  or  amaurosis,  nothing  can  be  done  for 
its  relief  until  the  latter  diseases  are  removed.  When  adhesions 
exist  the  difficulty  of  an  operation  is  always  increased,  and  such 
cases  are  extremely  liable  to  terminate  unfavorably. 

Diagnosis. — There  are  a  number  of  the  diseases  of  the  eye 
with  which  cataract  may  be  confounded.  Nor  is  their  diag- 
nosis at  all  times  easy,  for  those  of  the  most  experience  and 
skill  have  committed  errors.  As,  however,  the  diagnosis  mate- 
rially influences  the  future  conduct  of  the  surgeon,  its  correct- 
ness is  all-important ;  and  with  sufficient  care  may  be  made 
exact.  The  diseases  which  may  be  mistaken  for  cataract  are 
amaurosis  ;  glaucoma ;  fungus  haematodes  ;  opacity  of  the  cor- 
nea ;  and  adventitious  deposits  in  the  posterior  chamber,  and  be- 
fore the  crystalline  humor.  In  all  these  diseases  an  opacity  is 
perceptible  in  the  interior  of  the  eye  ;  but  they  all  possess  certain 
peculiarities  by  which  they  may  be  distinguished :  or  if  their 


29 

appearance  approach  so  nearly  to  that  of  cataract  to  render 
the  distinction  doubtful,  the  history  of  their  origin  and  progress 
will  decide  the  question. 

Cataract  and  Amaurosis. — In  some  forms  of  amaurosis  an 
organic  change  takes  place  in  the  condition  of  the  retina,  attri- 
buted to  a  deposition  of  fibrin  within  its  naturally  transparent 
texture.  This  causes  an  opacity  which  is  apparent  on  examina- 
tion, but  which  differs  from  that  of  cataract  in  appearing  very 
deeply  situated  in  the  eye.  It  is  seldom  very  dense  like  cata- 
ract, but  a  dim,  diffused  cloudiness  is  seen  behind  the  pupil ; 
and  if  this  be  dilated  by  stramonium  the  patient's  vision  is  not 
improved.  With  this  opacity,  insufficient  in  its  apparent  den- 
sity to  account  for  great  diminution  of  sight,  vision  may  be 
entirely  lost ;  and  if  the  disease  exist  in  both  eyes,  the  patient 
may  be  involved  in  total  darkness.  In  cataract,  light  is  al- 
ways perceptible.  Where  the  sight  in  amaurosis  is  still  re- 
tained to  some  extent,  the  diminution  is  not  proportionate  to  the 
opacity ;  and  now  an  important  symptom  is  manifested.  If  a 
strong  light  be  presented  to  the  eye,  vision  is  improved,  owing 
to  the  powerful  stimulus  given  to  the  sensibility  of  the  retina. 
Persons  having  cataract  see  more  distinctly  by  a  very  moderate 
light.  There  is  a  peculiar  difference  in  the  appearance  of  the 
flame  of  a  candle  in  those  affected  with  cataract  or  amaurosis. 
The  flame  appears  to  an  amaurotic  eye,  surrounded  with  a  halo  of 
various  colors  ;  while  the  halo  in  cataract  is  always  white,  ap- 
pearing composed  of  rays  of  light  radiated  from  the  flame  and 
somewhat  obscured  by  mist.  The  sight  in  amaurosis  is  not 
constant.  Though  it  continues  to  decline,  if  the  disease  be  not 
checked,  it  is  subject  to  fluctuations,  being  sometimes  worse,  and 
at  times  improved.  This  is  not  invariably  the  case.  Some- 
times flashes  of  light  dash  across  the  eye,  and  colored  spots,  or 
images  float  before  the  sight.  This  is  not  the  case  in  simple 
cataract.  Assistance  may  be  derived  from  the  state  of  the 
other  eye,  for  if  its  pupil  be  perfectly  clear,  but  the  eye  be 
amaurotic,  the  inference  may  be  that  in  the  suspected  eye  there 
is  also  amaurosis.     Again,  the  condition  of  the   iris  constitutes 


30 

a  valuable  diagnostic.  The  iris  in  amaurosis  may  be  either 
preternaturally  contracted  or  relaxed ;  and  in  either  state  may 
be  motionless  ;  it  may  be  sluggish  in  its  movements,  or  may 
retain  its  natural  action.  It  seldom  remains  perfectly  natural. 
When,  however,  the  pupil  is  thus  dilated  or  contracted,  and  this 
state  is  not  manifestly  owing  to  a  cataract  of  unusual  size  coming 
in  contact  with  it,  it  is  evident  the  disease  is  amaurosis,  (or  glau- 
coma). Were  these  distinctions  insufficient,  the  accession,  and 
progress  of  the  affection,  in  the  course  of  which  the  opacity  was 
produced,  would  determine  its  being  cataract  or  amaurosis. 
I  have  said  that  cataract  was  formed,  except  in  some 
traumatic  cases,  without  derangement  of  the  general  health. 
The  contrary  occurs  in  amaurosis.  This  disease  commen- 
ces with  an  increased  sensibility  to  light ;  and  clearness  of 
vision,  which  is,  however,  of  short  duration,  and  is  succeeded  by 
diminished  sight.  Pain,  frequently  of  the  most  agonizing  inten- 
sity, and  violence  is  experienced  in  the  head  or  eye.  In  the  more 
chronic  form,  a  severe,  but  dull  pain  is  suffered  in  the  forehead 
just  over  the  orbit,  or  it  may  be  confined  to  the  globe  of  the 
eye.  It  is  always  of  an  obstinate  character.  Amaurosis,  how- 
ever, frequently  occurs  without  its  presence.  Pain  in  the 
head,  or  a  deep-seated  pain  in  the  eye  infallibly  indicates  that 
the  opacity  in  question  is  not  cataract ;  or,  if  it  be  proved 
from  other  reasons  that  the  eye  contains  a  cataract,  that  it  is 
complicated  with  other  internal  disease  of  the  organ.  The 
acuteness  of  the  amaurotic  inflammation,  or  the  continued  pain 
in  the  head,  seldom  fail  to  derange  the  general  health,  and  this 
derangement  is  usually  manifested  in  the  digestive  organs. 
Amaurosis  is  likewise  a  frequent  consequence  ofsuch  disorder  : 
thus  it,  together  with  the  resulting  pain  in  the  head,  often  pre- 
cede by  several  months  the  disease  in  the  eye.  However  this 
may  be,  derangement  of  the  digestive  organs,  occurring  in  con- 
junction with  the  pain  in  the  head,  together  with  the  local  symp- 
toms enumerated,  is  an  important  auxiliary  in  determining  the 
diagnosis. 

Cataract   and   Glaucoma. — Glaucoma  is  an  inflammation, 


31 

either  acute  or  chronic,  of  the  vitreous  humor,  in  which  its 
transparency  is  lost.  The  opacity  thus  produced  may  be  mis- 
taken for  cataract.  Its  giadual  increase  causes  obscurity  of 
vision,  as  in  the  formation  of  the  latter  disease  ;  but  it  differs 
from  it  in  color,  in  apparent  volume,  and  in  depth  of  situation. 
The  commencement  of  the  disease  is  attended  with  pain  either 
m  the  eye,  or  forehead,  and  it  seldom  continues  long  without 
producing  amaurosis,  iritis,  and  cataract  itself,  with  general  in- 
flammation of  the  globe  of  the  eye.  The  opacity  is  of  a  green,  or 
greenish  yellow  color — very  different  in  this  respect  from  cata- 
ract. It  appears  very  deep  in  the  eye,  and  is  sometimes  evi- 
dently concave  anteriorly.  The  opacity  is  diffused,  like  a 
cloud,  but  has  a  shining  appearance,  so  as  sometimes  to  resem- 
ble a  piece  of  polished  metal  in  the  eye.  Occasionally  the 
arteria  centralis  retinas  may  be  seen  running  through  it.  Not- 
withstanding that  an  evident  space  may  be  distinguished  be- 
tween the  iris  and  the  opaque  substance,  the  functions  of  the 
former  arc  generally  deranged.  The  iris  becomes  languid  in 
its  movements  ;  often,  is  altered  in  color  and  thickness.  It  will 
frequently  be  found  contracted,  or  relaxed,  and  also  motionless. 
A  remarkable  effect  of  glaucoma,  in  many  cases,  is  to  render 
the  iris  tremulous ;  and,  if  the  vitreous  humor  be  increased  in 
volume,  it  may  be  pressed  forward  so  as  to  appear  convex  ;  or 
it  may  even  be  forced  against  the  cornea.  Another  important 
diagnostic  is  the  condition  of  the  globe.  In  cataract,  it  re- 
mains natural.  Glaucoma  frequently  deforms,  renders  it  soft, 
and  lessens  the  thickness  of  the  external  tunics.  A  glaucoma- 
tous eye  appears  blue  from  the  choroid  being  seen  through  the 
sclerotic,  and  large  varicose  vessels  generally  run  beneath  the 
conjunctiva,  Disordered  health  then;  pain;  loss  of  sight  dis- 
proportionate to  the  degree  of  opacity,  and  frequently  total 
blindni  --:  together  with  the  green  color  of  the  opacity,  and 
derangement  of  the  iris,  attend  this  complaint  and  clearly  dis- 
tinguish it  from  cataract. 

("i'n  act    and    /''i/./i'j'/s    Ha;mat,o(l<j:;. — The   opacity   which 


32 

characterizes  the  commencement  of  fungus  nematodes,  has  too 
remarkable  an  appearance  to  be  readily  mistaken  for  cataract. 
The  opaque  body  is  seen  deeply  located  in  the  posterior  part  of 
the  eye,  and  has  a  light  yellow  color,  often  approaching  that  of 
amber.  It  appears  like  a  polished  metalic  disk ;  often  seems 
concave,  and  sometimes  the  iris  may  be  seen  reflected  upon  it. 
When  it  has  increased  in  size,  its  surface  is  irregular,  and  by 
this  time  sight  is  destroyed.  Its  progress  is  accompanied  with 
fever,  and  a  peculiar  languor.  The  most  distressing  pain  both 
in  the  head  and  eye,  attend  its  course  at  irregular  intervals. 
When  the  fungus  has  arrived  at  the  pupil,  its  amber  color 
might  cause  it  to  be  pronounced  cataract,  did  not  the  history  of 
the  case,  the  loss  of  sight,  the  disordered  iris,  and  its  occurrence 
for  the  most  part  during  childhood,  almost  preclude  the  pos- 
sibility of  error. 

Cataract  and  Opacity  of  the  Cornea. — The  only  condition  of 
the  cornea  which  is  liable  to  occasion  an  incorrect  diagnosis,  is 
a  slight  nebula,  situated  on  its  posterior  lamina,  and  near  the 
centre.  Such  an  opacity  has  been  pronounced  cataract.  The 
diagnosis  is  of  much  importance,  for,  on  the  supposition  that  the 
case  was  a  forming  cataract,  a  patient  might  be  directed  to 
wait  for  its  completion,  during  which  time  the  corneal  opacity 
may  become  too  fixed  for  treatment,  and  might  have  been 
cured.  If  the  eye  be  examined  obliquely,  the  superficial  situa- 
tion of  the  disease  will  be  discovered,  while  behind  it  may  be 
seen  the  iris  with  a  perfectly  black  pupil.  The  sight  is  only 
obscured,  and  the  eye  manifests  no  other  derangement. 

Cataract  and  adventitious  deposit  before,  the  Lens. — The 
sequel  of  iritis  is  frequently  an  effusion  of  fibrin  or  purulent 
matter  in  the  posterior  chamber,  where  it  appears  like  a  mem- 
brane, and  may  be  mistaken  for  cataract.  Such  depositions 
have  been  termed  false  cataracts  They  are  either  of  a  white 
or  yellow  color,  and  appear  dull,  and  irregular.  The  iris  is 
generally  adherent  to  them,  and  presents  marks  of  having  suf- 
fered from  disease.     At  times,  these  deposits  project  into  the 


33 

anterior  chamber,  and  then  become  more  easily  recognized. 
An  effusion  of  blood  in  this  manner  has  been  seen,  the  deposit 
appearing  white,  with  red  spots  scattered  on  its  surface. 

Causes. — The  known  exciting  causes  of  cataract  are  nu- 
merous, and  for  this  reason  the  disease  is  not  an  uncommon 
one.  It  may  arise  from  injury,  either  direct  or  indirect,  inflicted 
on  the  lens  and  capsule  by  external  violence.  The  presence 
of  a  sense  of  fulness  and  distention  in  the  eye  during  its  forma- 
tion, shows  it  sometimes  to  result  from  congestion  of  the  organ. 
An  extension  of  the  inflammation  in  iritis,  amaurosis,  &c.  to  the 
capsule  of  the  lens,  is  often  its  cause.  Too  constant  use  of  the 
eye  in  literary  pursuits,  or  in  such  of  the  arts  as  require  minute 
and  long-continued  inspection,  particularly  if  with  this  an  unu- 
sually strong  light  be  employed,  however  unaccountable  its 
action  on  the  lens  may  be,  yet  frequently  gives  rise  to  cataract. 
The  affection  as  it  occurs  in  old  persons,  or  the  senile  cataract, 
is  frequently  insidious,  and  slow  in  its  approach,  requiring  several 
years  for  its  completion,  and  happens  to  those  in  other  re- 
-  so  perfectly  healthy,  that  it  cannot  be  attributed  to  any 
known  cause.  Not  a  few  cases  are  also  on,  record  where  the 
disease  was  hereditary  ;  in  some  of  which  as  many  as  five  of  a 
family  have  been  affected.  I  have  seen  Dr.  Delafield  operate 
on  two  of  a  family  at  once,  for  congenital  cataract,  in  which  all 
the  children  had  been  born  with  the  disease.  Mr.  Stratford, 
of  London,  states  that  congenital  cataract  frequently  occurs 
after  protracted  labor  ;  and  considers,  that  in  the  compression 
which  the  frontal  bone  experiences,  the  globe  must  also  be 
compressed,  by  which  means  the  delicate  vessels  attaching  the 
to  its  capsule  arc  ruptured,  and  cataract  consequently 
is.  In  thus  explaining  congenital  cataract,  he  states  that 
ii  may  also  result  from  local  chronic  inflammation.  It  may  not 
be  an  altogether  fanciful  conjecture,  to  imagine,  that  this  cata- 
netim  -  the  consequence  of  the  rupture  and  absorp- 
tion of  the  membrana  pupillaris.  The  arteria  centralis  retinas, 
which  branches  to  the  capsule  of  the  lens,  also  in  the 

in  tus  supplies   this   membrane.     The  increased   action  which 


34 

takes  place  by  the  rupture  of  these  branches,  and  by  the  absorp- 
tion which  is  going  on,  may  occasion  a  slight  deposition  of 
fibrin ;  and,  an  obstruction  once  created  in  the  course  of  the 
vessels,  would  cause  total  opacity  of  lens  and  capsule. 

There  appears  much  reluctance  in  the  writers  on  cataract 
to  consider  it  the  result  of  actual  inflammation  and  the  terms 
"  acute"  and  "  chronic  inflammation,"  or  "  irritation,"  as  they  are 
applied  to  other  diseases  are  seldom  used.  But  traumatic  cat- 
aract clearly  shows  that  acute  inflammation  may  occur  in  the 
lens  and  capsule,  as  well  as  in  the  other  tissues  of  the  eye ; 
while  the  result  of  the  inflammation  is  a  cataract  similar  in  its 
formation  and  appearance  to  that  whose  progress  is  almost  im- 
perceptible. When  also,  the  disease  is  not  the  consequence  of 
external  injury,  its  course  is  sometimes  attended  with  a  manifest 
sense  of  fulness  and  distention,  or  even  pain,  in  the  eye.  Again 
in  the  cases  where  the  cataract  is  rapidly  formed,  if  the  pupil 
be  examined  with  a  magnifying  glass,  vessels  may  be  seen  ram- 
ifying over  the  capsule,  which  in  the  healthy  eye  are  invisible  ; 
proving  an  increase  of  the  circulating  fluids  of  the  part.  These 
fluids  are  naturally  transparent ;  but  in  disease,  they  are  denser, 
or  acquire  a  more  or  less  white  color.  The  increase  of 
volume  which  the  cataract  sometimes  possesses  over  the  natural 
size  of  the  capsule  and  lens,  must  be  the  result  either  of  deposi- 
tion of  fibrin  in  their  texture,  or  of  an  increased  secretion  of 
the  fluid  of  Morgagni ;  while,  in  other  cases,  the  gradual  absorp- 
tion of  the  contents  of  the  capsule,  until  only  a  shrivelled  mem- 
branous or  capsular  cataract  remains  proves  that  all  the  results  of 
inflammation  in  other  parts,  viz :  deposition  of  fibrin  ;  preternatu- 
ral secretion ;  and  subsequent  absorption,  also  take  place  here. 
The  low  degree  of  vitality  attributed  to  these  parts  by  some 
authors,  renders  them,  they  think,  insusceptible  of  inflammation  ; 
and  some  affirm  that  the  lens  has  no  vitality.  But  can  a  body  pos- 
sessed of  such  a  perfect  organization,  and  wherein  the  natural 
processes  of  exhalation  and  absorption,  must  continue  with  the 
most  undeviating  exactness,  to  preserve  the  transparency  of 
these  delicate  parts  have  a  low  degree  of  vitality  ?  or  rather, 


35 

must  not  these  functions  possess  a  very  high  degree  of  vitality 
to  continue  their  healthy  condition,  notwithstanding  the  frequent 
abuse  of  the  organ  from  exposure,  and  improper  or  excessive 
employment  ?  And  if  they  possess  this  vitality,  together  with 
unusual  delicacy  of  structure,  are  they  not  also  liable  to  all  the 
derangements  to  which  all  other  highly  organized  parts  are  sub- 
ject ?  If  acute  inflammation  can  occur  in  the  lens  and  capsule, 
as  proved  in  traumatic  cataract,  chronic  inflammation  may  also 
take  place,  because  wherever  the  acute  form  has  been  known, 
the  subacute  has  also  existed.  And  the  pathology  of  both  are 
essentially  the  same.  In  regard  to  the  senile  cataract,  may  not 
a  slow  deposition  of  fibrin  take  place  in  the  lens,  in  the  same 
manner,  and  by  the  same  morbid  action,  as  occurs  in  the  depo- 
sition of  bone  in  the  arteries  of  old  persons  ?  If  the  production 
and  developement  of  miliary  tubercles  in  the  lungs  is  sometimes 
so  imperceptible  that  no  idea  of  their  progress  can  be  formed, 
and  they  are  allowed  to  be  the  result  of  chronic  inflammation  or 
irritation,  I  should  imagine  the  same  tardy  action  in  the  vessels 
of  the  lens  and  capsule  might  occasion  an  equally  slow  produc- 
tion of  cataract.  The  exciting  causes  then  being  ascertained, 
and  the  proximate  cause,  or  in  other  words,  the  disease  itself 
being  understood,  as  much,  I  believe,  is  known  of  the  cause  of 
cataract  as  of  any  other  disease. 

Prognosis.  The  treatment  of  cataract  has  contributed 
much  to  enhance  the  reputation  of  surgery.  So  rapid  and 
palpable  is  its  effect,  and  so  perfect  the  relief  afforded,  that  it 
cannot  but  be  beheld  with  wonder  anu  admiration.  The  inge- 
nuity to  devise,  and  the  boldness  to  execute  the  operation 
called  couching  must  have  elevated  Celsus,  who  first  performed 
it,  to  the  highest  place  in  the  esteem  of  his  countrymen,  and  of 
his  profession. 

Nothing  is  available  in  the  cure  of  cataract  but  a  surgical 
operation,  and  that  may  be  completely  effectual.     To  those 

however.  ;n<ii^toiiie(l  to    imagine  a  far    less    injury  to  the   eye 

than  is  produced  by  plunging  an  instrument  to  its  centre,  as 

fatal  to  vision,  the  surprise    at   the   proposal  of  an   operation   is 


36 

only  equalled  by  their  dread  of  its  severity.     Such  are  in  con- 
sequence extremely  solicitous  to  know  its   result ;  and  if  their 
joy  and  happiness  in  its  success  be  great,  their  disappointment 
at  its  failure  is  still  more  manifest.     In  its  event,  therefore,  the 
reputation  of  the  surgeon  is  greatly  concerned :  and  his  duty,  so 
far  to  warn  his  patient  of  the  dangers  which  surround  him,  and 
of  the  liability  of  the  operation  to  failure,  as  not  to  deter  his 
attempting  the  last  expedient,  without  affording  a  too  flattering 
prospect  of  relief,  is  delicate  and  difficult  in  the  extreme.     Yet 
this  is  the  only  just,  and  proper  course.     The  complications  of 
the  disease  are  numerous,  and  the  result  of  an  operation  is 
always  involved  in  uncertainty.     To  the  inquiry  if  the  cataract 
will   not  disappear  without   an  operation,  the   reply  may  be 
given,  that  when  once  produced,  it  always  remains.     It  is  true 
that  a  few  cases  are  known  where  spontaneous  cure  Occured, 
but  such,  only  go  to  prove  the  general  rule.     The  most,  likewise, 
of  the  reported  cases  are  those  of  traumatic  cataract  in  which 
accident  rudely  executed  what  the  surgeon  would  have  per- 
formed with  more  neatness.     A  more  genuine  instance  of  spon- 
taneous cure  is  reported  by  Mr.   Estlin  of  Bristol.      Med. 
Gazette,  vol.  3,  p.  566.     A  simple  mature  cataract  occuring  in  a 
person  whose  habit  is  rather  spare,  and  who  leads  a  temperate 
life,  is  the  most  favorable  for  operation.     But  little  doubt  of 
success  need  here  be  entertained,  and  it  is  fortunate  for  surgery 
that,  as  I  am  informed  by  Dr.  Delafield,  the  great  majority  of 
the  cases  of  cataract  which  occur  in  practice  are  free  from 
complication  with  other  diseases.     It  is  unadvisable,  however, 
to  operate  where  only  one  such  cataract  exists,  for  though  the 
event  be  satisfactory,  the  sound  eye  will  alone  be  used.     The 
only  reason  for  exposing  the  person  to  the  dangers  of  inflamma- 
tion which   may    follow  the    operation,   being   the    improved 
appearance  of  the  face.     Mr.  Travers'  advice  in  this  case  is  to 
operate,  his  reasons  for  which,  he  gives  in  his  work  on  the  eye, 
p.  338,  but  it  has  been  overruled  by  other  authority. 

The  removal  of  such  a  cataract  in  a  plethoric  person,  or  one 
whose  constitution  is  broken,  whose  health   is  deranged,  or 


37 

whose  habits  are  intemperate,  is  attended,  even  after  careful 
preparatory  treatment,  with  much  liability  to  inflammation 
from  the  incision,  and  the  injury  done  the  internal  parts  of  the 
eye ;  and  of  this  the  patient  should  be  forewarned.  Indeed,  if 
the  general  health  be  deranged,  no  operation  should  be  attempt- 
ed until  measures  have  been  taken  to  repair  it.  Derangement 
of  the  stomach  and  bowels ;  a  rheumatic  diathesis ;  the  presence 
of  pulmonary  catarrh ;  or  eruptive  diseases,  all  tend  to  occasion 
an  unfavorable  termination,  and  should  therefore  modify  the 
prognosis.  The  existence  of  hoemorrhoids,  or  of  obstinate  con- 
stipation, are  also  enumerated  by  Dupuytren,  as  reasons  for  de- 
ferring an  operation.  On  the  other  hand,  if  a  perfectly  formed 
cataract  exist  in  one  eye,  while  the  other  is  affected  by  the  in- 
cipient disease,  an  operation  should  be  performed,  that  the  indi- 
vidual may  not  be  deprived  of  sight  during  its  completion. 
Where  two  mature  cataracts  exist,  one  only  should  be  removed 
at  a  single  operation.  The  practice  of  some  surgeons,  at  once 
to  remove  both,  exposes  the  patient  to  a  greater  danger  of  sub- 
sequent inflammation ;  or,  if  by  untoward  circumstances,  the 
operation  fail,  there  is  no  further  resource,  unless  a  secondary 
operation  be  practicable.  In  complications  of  the  cataract  with 
other  local  diseases,  the  prognosis  is  always  unfavorable.  If 
amaurosis,  or  glaucoma  be  present  to  any  extent,  an  operation 
is  not  only  useless,  but  reprehensible,  from  the  great  liability  to 
excite  violent  inflammation  where  disease  already  exists.  It  is 
said  that  in  mild  cases  of  amaurosis,  when  the  progress  of  the 
se  is  arrested,  and  the  retina  retains  some  sensibility  to 
light,  tin;  cataract  may  be  removed  with  advantage.  If,  how- 
ever, in  such  cases  tin:  patient  wore  informed  of  the  danger  of 
supervening  inflammation,  the  only  partial  relief  he  will  obtain, 
and  the  probability  that  his  sight  would  always  be  weak,  and 
insufficient,  he  would  generally  decline  an  operation.  The  eye 
i~  fp  quently  subject  to  rheumatic  inflammation,  which  locates  it- 
self [neither  the  sclerotic  coat,  or  the  iris.  Where  iliis  disposition 
prevails,  the  removal  of  ;i  cataract  is  extremely  liable  to  excite, 
or  renew  the  disease  in  these  tunics.    This  is  not,  however, 


38 

a  sufficient  reason  to  prevent  an  operation  and  consign  a  patient 
to  blindness.  If  due  preparatory  treatment  be  used  ;  care  be 
had  to  meet  with  active  remedies  the  least  sign  of  subsequent 
inflammation,  and  the  patient  be  advised  of  the  hazard,  it  may 
be  attempted  with  propriety.  Extensive  adhesions  of  the  iris  to 
the  capsule  of  the  lens  should  forbid  an  operation,  for  the  lesion 
produced  in  the  attempt  to  detach  it  would  not  fail  to  cause 
destructive  inflammation.  When,  however,  the  attachments  are 
slight,  as  by  single  shreds  or  points,  and  the  pupil  is  fully  dilated 
by  stramonium,  a  skilful  surgeon  will  readily  divide  them,  and 
remove  the  cataract.  Opacities  of  the  cornea,  occurring  in 
conjunction  with  cataract,  must  be  removed,  if  possible,  pre- 
viously to  an  operation.  It  is  in  some  such  cases  that  the  eye 
displays  the  great  extent  to  which  it  will  bear  surgical  opera- 
tions, and  also  the  great  recuperative  powers  of  the  system. 
Sometimes  the  corneal  opacity  may  be  removed  by  medical 
treatment  from  all  but  the  centre  of  the  membrane,  the  cataract 
may  be  dislodged,  and  finally  the  operation  to  form  an  artificial 
pupil,  may  be  successfully  accomplished.  If  the  corneal  opacity 
be  great,  operations  upon  a  cataract  are  obviously  without  ad- 
vantage. In  congenital  cataract,  a  favorable  prognosis  may 
always  be  given.  The  injury  inflicted  by  the  operation  being 
slight,  the  liability  to  consecutive  inflammation  is  diminished  ; 
the  cataract  is  soft,  and  being  broken  up,  presents  ample  surface 
for  the  action  of  the  absorbents ;  while  the  great  activity  with 
which  the  vital  functions  are  performed  ensures  its  rapid  ab- 
sorption. The  prognosis  of  the  traumatic  form  must  necessarily 
be  uncertain.  If  it  arise  from  concussion,  some  other  disease 
will  generally  accompany  it.  When  it  is  the  result  of  a  direct 
injury,  and  the  lens  is  dislodged,  an  immediate  operation  may 
be  necessary,  but  its  result,  in  regard  to  sight,  must  depend 
upon  the  degree  of  injury  primarily  inflicted,  and  the  event  of 
an  additional  wound  in  an  already  inflamed  organ.  Where  the 
cataract  exists  after  the  subsidence  of  all  inflammation,  and 
there  is  no  other  complication  present,  it  may  be  removed  with 
a  sanguine  hope  of  success.     It  is  frequently  necessary  to  repeat 


39 

the  operation  in  consequence  of  incomplete  absorption,  or  of  the 
formation  of  a  capsular  cataract  after  the  lens  has  been  removed, 
and  in  giving  an  opinion  upon  the  result  of  an  operation,  this 
should  always  be  clearly  stated. 

Another  source  whence  assistance  may  be  derived  in  esti- 
mating the  probable  success  of  an  operation,  is  the  comparative 
result  of  previous  experience.  The  practice  of  Dr.  Delafield 
has  led  him  to  estimate  the  proportion  of  successful  operations 
at  about  six  in  seven  cases.  This  is  not,  however,  the  propor- 
tion of  cures  without  supervening  inflammation.  In  rather  more 
than  one  half  the  cases,  he  thinks,  inflammation  occurs  subse- 
quent to  an  operation,  and  this  is  only  removed  by  the  most 
active  treatment.  In  fine,  then,  the  prognosis  of  a  simple  idio- 
phatic  cataract,  as  the  congenital  or  senile,  may  be  as  favora- 
ble as  the  usual  certainty  of  operations  will  allow.  The  symp- 
tomatic, or  that  resulting  from  other  general  or  local  affections, 
offers  less  hope  of  perfect  relief.  The  complicated  cases  de- 
pend upon  the  extent  of  internal  disorganization  ;  and  the  trau- 
matic varieties  are  involved  in  uncertainty,  in  which  the  judg- 
ment of  the  surgeon  must  be  exercised  according  to  the 
individual  peculiarities  of  the  case. 

Treatment. — It  is  now  universally  admitted,  that  no  treat- 
ment is  of  any  avail  in  the  cure  of  cataract,  but  its  removal  from 
the  axis  of  vision  by  a  surgical  operation.  Recurrence,  there- 
fore, to  the  various  modes  of  medical  treatment,  which  have 
been  attempted,  as  the  use  of  narcotics,  stimulants,  and  counter- 
irritants  is  unnecessary. 

There  is  DO  operation  in  surgery  which  involves  more  medi- 
cal and  surgical  skill,  than  that  for  the  removal  of  cataract. 
Minute  anatomical  knowledge,  an  extensive  acquaintance  with 
theraputics,  combined  with  the  greatest  skill  and  delicacy  in 
Burgeiy,  an:  here  in  requisition.  The  utmost  quickness  of  per- 
ception to  detect  the  accidents  which  i  hrcaten  every  step  oft  ho 
Burgeon's  progress,  must  be  combined  with  the  most  prompt 
and  dexterous  execution  to  counteract  their  occurrence. 

No  case  of  cataract  present!  itself  which  is  prepared  for  im- 


40 

mediate  removal.  A  preparatory  treatment  of  greater  or  less 
extent,  according  to  the  condition  of  the  system,  is  always  re- 
quired. The  great  liability  of  the  eye  to  severe  subsequent 
inflammation,  demands  the  closest  attention,  and  often  the  de- 
cided energy  of  the  surgeon.  Indeed,  it  has  been  remarked  by 
Dr.  Delafield,  that  the  success  of  an  operation  is  as  much  depend- 
ant upon  the  preparatory,  and  subsequent  treatment,  as  upon 
the  operation  itself.  The  treatment  of  cataract  is  hence  sub- 
ject to  three  divisions.  1st,  the  preparatory  treatment ;  2d,  the 
operation  ;  and  3d,  its  subsequent  management. 

1.  The  indications  for  preparatory  treatment  are  derived 
from  the  temperament  of  the  person,  the  general  health,  and 
the  local  condition  of  the  eye.  A  simple  cataract  appearing  in 
a  spare  habit,  and  a  sound  constitution,  is  in  the  most  favorable 
state  for  operation.  The  only  treatment  which  need  here  pre- 
mise it,  is  an  abstemious  diet  for  a  few  days  ;  attention  to  the 
digestive  organs  ;  and  venesection  the  previous  evening  if  there 
be  the  least  pain,  or  sense  of  fulness  about  the  head  or  eye.  It 
is  always  important  that  one  or  two  active  cathartics  be  given 
at  the  outset,  and  that  the  bowels  be  then  kept  in  a  free  con- 
dition by  milder  aperients.  Venesection  the  preceding  evening 
or  morning  would  probably  seldom  be  injurious,  unless  debility 
exist,  and  is  frequently  necessary.  When  the  consequences  of 
insufficient  preparation  are  so  dangerous,  the  fear  of  doing  a 
little  too  much  need  not  be  dreaded.  There  is  less  liability  to 
subsequent  inflammation,  and  the  surgeon  proceeds  with  more 
confidence.  Plethoric  persons  and  those  disposed  to  determina- 
tion of  blood  to  the  head,  require  active  depletion.  Venesec- 
tion should  be  repeated  several  times,  strict  diet  be  enjoined, 
and  a  cathartic  be  administered  every  two  or  three  mornings 
for  a  couple  of  weeks  previously  to  the  operation.  And  notwith- 
standing all  this  reduction,  inflammation  is  very  apt  to  supervene. 

If,  together  with  this  habit  of  body,  the  health  be  impaired, 
as  indicated  by  a  furred  tongue,  deranged  digestion,  and  dimin- 
ished or  capricious  appetite,  the  use  of  evacuants,  regulated  ac- 
cording to  the  condition  of  the  bowels,  is  of  the  highest  impor- 


41 

r 

tance.  The  health  must  be  restored  by  several  weeks'  strict 
attention  to  a  proper  diet.  In  such  cases,  calomel  in  small 
doses,  or  the  pil :  hydrarg :  taken  at  night,  and  followed  the  next 
morning  by  sulph :  magnes :  alone,  or  with  senna ;  or  the 
eccoprotic  mixture  are  preferable  to  drastic  purgatives.  The 
warm  bath  to  excite  a  healthy  action  in  the  cutaneous  vessels, 
may  be  in  many  instances  productive  of  advantage.  By  these 
means,  the  tongue  will  resume  its  natural  appearance ;  the  ap- 
petite, and  digestion  be  restored ;  and  a  manifest  improvement 
is  often  observed  in  the  disposition,  and  countenance  of  the 
patient.  When  this  derangement  of  health  occurs  in  more 
weak,  and  nervous  constitutions,  the  same  treatment,  exclusive 
of  the  free  loss  of  blood,  is  indicated. 

The  presence  of  any  rheumatic  affection  is  a  serious  obsta- 
cle to  success,  and  an  operation  should  be  delayed  until  all  the 
symptoms  are  removed  by  appropriate  treatment. 

A  rheumatic  diathesis  is  always  unfavorable  to  operations 
on  the  eye.  The  wound  is  extremely  liable  to  excite  the  pecu- 
liar inflammation  of  rheumatism  in  either  the  fibrous  sclerotic 
coat,  or  in  the  iris.  On  this  account  the  state  of  the  weather 
should  be  carefully  regarded  in  determining  the  time  for  opera- 
tions. Indeed,  the  remark  may  be  extended  to  all  persons, 
without  confining  it  to  the  rheumatic.  I  saw  the  result  of  an 
operation  during  the  last  winter  held  a  long  time  in  doubt  from 
an  unavoidable  exposure  to  cold.  The  patient  being  obliged  to 
remain  in  a  cold  room,  after  having  undergone  active  prepara- 
tory depletion  was  attacked,  after  the  operation,  with  extremely 
severe  internal  and  external  ophthalmia.  It  obstinately  resisted 
b< >th  general,  and  local  depletion,  as  well  as  mercurials,  and 
counter  irritants,  until  the  patient  was  removed  to  a  more  com- 
fortable apartment.  The  disease  then  rapidly  yielded  to  treat- 
ment. 

The  failure  of  some  cases  has  been  clearly  traced  to  the  ex- 
istence  of  eruptive  diseases.  U,  therefore,  any  such  be  disco- 
vered, tin  v  should  be  subjected  to  treatment  before  the  cataract. 

Pulmonary  diseases  an;  likewise  prejudicial  to  the  treatment. 

ft 


42 

The  act  of  coughing,  they  occasion,  according  to  Mr.  Dupuy- 
tren,  produces  congestion  of  the  head,  which  may  be  the  means 
of  exciting  ophthalmia. 

In  regard  to  the  condition  of  the  eye  itself,  the  presence 
of  any  inflammation,  or  irritation  about  the  organ  must  be 
completely  removed  before  an  operation  is  commenced,  ex- 
cept in  cases  of  traumatic  cataract,  where  the  lens  acts  as  a 
foreign  substance  to  keep  up  inflammation.  Such  traumatic 
cases  are  only  to  be  operated  upon  after  the  most  decided 
depletion.  If  amaurosis  or  iritis  exist,  the  remedies  em- 
ployed in  those  affections  must  be  premised  until  no  trace  of 
those  diseases  be  left.  Sometimes  a  slow  disorganizing  action 
goes  on  in  the  vitreous  humor  until  the  lens  looses  its  support, 
and  falls  into  the  anterior  chamber.  After  a  time  the  disease  is 
recovered  from,  and  the  vitreous  humor  is  restored  to  a  healthy 
state.  It  is  then,  that  the  dislocated  lens  may,  with  propriety, 
be  removed.  Five  or  six  such  cases  have  occurred  to  Dr.  Dela- 
field,  upon  which  he  has  operated  at  this  period  with  entire 
success.  When  the  health  has  been  thus  restored,  and  the  eye 
reduced  to  a  perfectly  quiet  condition,  the  only  remaining  pre- 
caution is  to  secure  an  ample  dilatation  of  the  pupil  by  means 
of  the  extract  of  stramonium,  or  belladonna.  This  should  be 
applied  in  a  thick  paste  around  the  palpebrae  the  evening,  and 
morning  preceding  the  operation.  When  used,  it  should  be 
kept  moist  for  some  time  to  promote  its  absorption. 

2.  The  Operations. — The  controversy  which  the  opera- 
tions proposed  for  the  cure  of  cataract  have  occasioned,  has 
elicited  the  most  minute  and  extended  descriptions.  Objections, 
fancied  and  real,  have  been  advanced  against  them  ;  and  each 
has  been  extolled,  to  the  exclusion  of  the  others,  by  the  various 
writers  who  have  invented  them,  or  practised  them  with  the 
greatest  facility.  To  describe  all  these  minutiae,  to  examine 
and  relate  the  objections,  and  detail  all  the  precautions  enumera- 
ted, would  only  be  to  make  a  prolix  rehearsal  from  these  authors. 
I  shall,  therefore,  briefly  mention  the  different  operations,  and 
the  manner  of  performing  them  as  now  generally  received  ;  the 


instances  to  which  they  are  severally  the  best  adapted ;  and  the 
instruments  at  present  preferred. 

There  are  three  operations  by  which  the  cataract  may  be 
removed,  viz.  by  depression;  by  extraction;  and  by  absorp- 
tion. 

1.  The  operation  by  depression,  or  couching,  as  it  is  also 
termed,  consists  in  removing  the  cataract  from  the  axis  of  vi- 
sion by  depressing  it  into  the  vitreous  humor,  where  it  remains 
until  reduced  by  the  action  of  the  absorbents.  This  method  has 
two  varieties,  called  the  anterior  and  posterior  operations : 
the  former,  implying  that  the  instrument  is  passed  into  the  cata- 
ract through  the  cornea,  the  anterior  chamber  of  the  aqueous 
humor  and  the  pupil ;  the  latter,  that  it  is  introduced  posteriorly 
to  the  iris,  through  the  opaque  membranes  of  the  eye,  and  the 
posterior  chamber.  The  terms  are  derived  from  the  circum- 
stances of  the  operation  being  performed  either  anteriorly,  or 
posteriorly  to  the  iris.  There  is  a  variety  of  the  posterior  ope- 
ration termed  reclination,  in  which  the  vertical  plane  of  the 
lens  is  made  the  horizontal  before  the  depression  is  commenced. 
This  method  is  now  abandoned. 

2.  The  operation  by  extraction  consists  in  making  a  section 
through  the  cornea  sufficiently  large  to  permit  the  exit  of  the 

which  is  detached  from  its  capsule,  and  pressed  through 
the  incision.  Of  this  operation  there  are  also  two  varieties ; 
one,  in  which  the  incision  is  made  along  the  inferior  margin  of 
the  cornea  ;  the  second,  in  which  it  is  carried  along  the  superior 
margin.  The  flap  of  the  cornea  in  the  former  is  turned  down- 
ward ;  in  the  latter  it  is  directed  upward. 

3.  The  operation  by  absorption  consists  in  introducing  an 
instrument  into  the  cataract,  breaking  it  up  without  dislodging 
it  from  the  axis  of  vision,  and  so  lacerating  the  capsule  that  the 
aqueoui  humor  is  admitted  upon  the  lens,  by  which  means  the 
latter  becomes  absorbed.  This  method  is  also  called  solution, 
from  an   opinion   thai   the   aqueous    humor  dissolved  the   lens. 

The  instrument  may  here  also  be  introduced  anteriorly,  or  pos- 


r      44 

teriorly  to  the  iris,  as  in  depression.     When  passed  through  the 
cornea,  the  operation  is  called  keratonyxis. 

Depression  was  first  performed  by  Celsus.  Extraction  was 
first  described  by  Daniel,  though  Freytag  first  practised  it  in  a 
case  where  the  lens  had  fallen  into  the  anterior  chamber.  The 
operation  by  absorption  was  discovered  by  Messrs.  Pott  and 
Hey. 

These  operations  are  severally  applied  to  the  varieties  of 
cataract,  as  they  prove  most  applicable  to  particular  cases.  In 
general,  depression  is  preferred  in  this  country,  but  extraction 
appears  to  be  the  favorite  in  Europe.  Dr.  Delafield  has  in- 
formed me  that  at  one  time  he  operated  alternately  by  extrac- 
tion, and  depression,  but.  finally  adopted  the  latter,  except  in 
particular  cases,  from  having  found  it  the  more  successful. 
M.  Dupuytren  once  gave  extraction  the  preference,  but  has 
since  given  his  opinion  in  favor  of  depression. 

When  either  of  these  operations  is  to  be  performed,  stramo- 
nium must  be  applied  to  the  eye  several  hours  previously,  that  the 
fairest  possible  view  may  be  obtained  of  the  cataract.  A  situ- 
ation is  then  selected  near  a  window,  at  which  a  full  light  enters, 
without  the  admission  of  the  rays  of  the  sun.  A  northern 
exposure  is  the  best  for  this  object.  Strong  light  should  be 
excluded  the  room  from  every  other  source.  The  object  in  the 
arrangement  of  the  light  is  to  permit  as  much  as  possible  to 
strike  the  eye,  but  in  such  a  manner  that  none  of  the  rays  re- 
flected from  the  cornea  shall  be  visible  to  the  operator.  If  the 
surgeon  operate  equally  well  with  both  hands,  the  patient  may 
always  sit  before  him,  but  if  he  only  use  the  right  hand,  the  pa- 
tient must  lie  down  when  the  right  eye  is  the  subject  of  opera- 
tion. The  surgeon,  in  the  latter  case,  places  himself  at  the  head 
of  the  table,  on  a  seat  so  elevated,  that  he  may  easily  overlook 
the  patient's  face.  When  the  sitting  posture  is  chosen,  the  sur- 
geon takes  a  position  partially  between  the  light  and  the  pa- 
tient, having  the  cataractous  eye  rather  to  the  right,  and  the 
nearer  of  the  two  to  the  window.     A  pledget  confined  by  a 


45 

slight  bandage  should  always  be  placed  over  the  eye  on  which 
no  operation  is  proposed.  The  patient  endeavors  to  see  what 
is  passing  before  him,  and  the  consequent  movement  of  the 
eye,  being  communicated  to  the  other,  prevents  its  being  kept 
at  rest.  This  difficulty  the  bandage  obviates.  The  seat  of  the 
patient  should  have  a  back  which  affords  a  firm  support  for  the 
head,  though  if  the  surgeon  have  a  steady  assistant,  he  may 
confine  it  against  his  breast  with  sufficient  firmness.  The  assis- 
tant who  supports  the  head,  also  elevates  the  lid  and  contrib- 
utes to  fix  the  eye.  The  management  of  the  lid  is  a  matter  of 
nicety.  The  assistant  should  first  partially  raise  the  lid,  with 
the  forefinger  of  the  left  hand,  to  enable  him  to  place  that  of 
the  right  distinctly  upon  the  tarsal  edge  of  the  lid,  under  the 
eyelashes.  He  then  elevates  it  to  the  orbital  ridge,  and  gently 
presses  on  the  globe  of  the  eye.  If  extraction  be  performed, 
he  must  not  press  in  the  least  upon  the  eye,  but  simply  elevate 
the  lid.  When  the  finger  is  placed  above  the  eyelashes,  instead 
of  on  the  tarsal  margin  of  the  lid,  the  action  of  the  eye  during 
the  operation  everts  the  lid,  the  fold  falls  over  the  cornea,  and 
the  surgeon  is  compelled  to  withdraw  his  instrument.  When 
the  cataract  is  to  be  removed  by  depression,  the  instrument 
used  is  called  a  couching  needle.  That  invented  by  Scarpa, 
with  some  modification,  is  now  generally  employed.  It  is  about 
an  inch  long,  with  its  pointed  extremity  slightly  curved  ;  the  con- 
cavity being  flat,  and  the  convex  surface  rounded.  Just  above 
the  curvature  the  diameter  of  the  needle  is  somewhat  dimin- 
ished. This  instrument  is  only  used  in  the  posterior  operation. 
The  anterior,  requires  Saunder's  straight  spear-pointed  needle. 
All  the  preliminary  arrangements  being  made,  the  operator 
the  needle  between  the  thumb  and  two  forefingers,  the 
second  being  advanced  nearer  the  needle  than  the  first.  The 
finger!  are  then  drawn  back,  that  the  instrument  may  be 
passed  into  the  eye,  by  their  action  alone,  and  not  by  a  move- 
ment of  the  hand  and  arm.  If  the  surgeon's  hand  be  un- 
steady, he  ma)  have  a  Bupport  for  the  elbow,  or  may  rest  the 
little  finger  on  the  patient's  cheek  bone  \  but  it  is  always  advisa- 


46 

ble  to  avoid  such  assistance,  as  it  interferes  with  the  free  mo- 
tion of  the  hand.  The  instrument  is  then  applied,  perpendicu- 
larly, to  the  sclerotic  conjunctiva  about  a  line  beyond  its  junc- 
tion with  the  cornea.  The  flat  surface  of  the  needle  should  be 
parallel  with  the  horizontal  plane  of  the  eye,  and  a  little  below 
its  centre,  in  order  to  avoid  dividing  the  long  ciliary  artery  be- 
tween the  sclerotic  and  choroid  coats.  The  needle  is  then 
passed  gently,  but  firmly  and  steadily  through  the  membranes, 
after  which  the  handle  is  immediately  directed  backward,  if  the 
patient  be  sitting ;  downward,  if  he  be  lying,  until  the  point  of 
the  needle  is  in  the  posterior  chamber  behind  the  iris.  Great 
care  is  necessary  to  avoid  wounding  or  passing  the  needle 
through  this  body.  Immediately  the  needle  enters  the  posterior 
chamber,  its  concave  surface  must  be  turned  towards  the  cata- 
ract. This  motion  will  consequently  directly  follow  the  back- 
ward, or  downward  movement  previously  directed.  The  point 
of  the  needle  is  now  advanced  until  distinctly  seen  through  the 
pupil,  to  the  centre  of  which  it  is  to  be  passed,  when  by  a 
prompt  action  it  is  thrust  through  the  capsule  into  the  lens. 
The  needle  is  then  in  the  situation  for  depressing  the  cataract. 
This  is  done  by  inclining  the  handle  upward  towards  the  fore- 
head. The  lens  and  capsule  are  thereby  torn  from  their  at- 
tachments and  forced  into  the  vitreous  humor,  where  they  be- 
come engaged,  and  remain.  The  needle  should  then  be  par- 
tially removed  to  discover  if  the  cataract  follow  it,  if  so  the 
depressing  motion  must  be  repeated  until  it  continues  in  the 
vitreous  humor.  When  the  cataract  is  lenticular,  the  transpa- 
rent capsule  may  remain  in  its  situation,  and,  becoming  after- 
wards opaque,  constitute  a  secondary  cataract.  To  prevent 
this,  the  point  of  the  needle  should  be  turned  previously  to 
being  withdrawn  from  the  eye,  towards  the  cornea,  and  be 
freely  moved  about  to  lacerate  the  capsule  and  thus  hasten  its 
absorption.  The  instrument  is  then  carefully  withdrawn,  and 
the  assistant  instantly  lets  fall  the  lid.  After  a  short  interval, 
the  eye  may  again  be  opened  to  examine  its  state,  and  gratify 
the  patient  with  a  moment's  enjoyment  of  vision.     It  is  then  to 


47 

be  immediately  closed,  and  covered  with  a  slip  of  muslin,  wet 
with  cold  water.  A  bandage  is  then  passed  around  the  head, 
having  a  little  drop  curtain  attached  which  falls  before  the  eye, 
and  excludes  the  light.  The  muslin  is  to  be  kept  constantly 
wet  with  cold  water,  and  the  patient  be  placed  in  a  darkened 
room.     Thus  terminates  the  operation. 

The  parts  through  which  the  needle  has  passed  to  arrive  at 
the  cataract,  are  the  conjunctiva,  the  sclerotica,  the  choroid 
membrane,  the  retina,  the  ciliary  processes,  and  the  posterior 
chamber  of  the  aqueous  humor.  In  the  depression  of  the 
cataract,  the  hyaloid  membrane  and  the  vitreous  humor  are 
injured. 

The  various  movements  of  the  instrument  while  in  the  eye 
must  be  made  by  employing  it  as  a  lever,  the  fulcrum  of  which 
is  the  membranes  punctured  by  its  introduction. 

It  is  seldom  that  the  instrument  takes  precisely  the  course 
described.  Instead  of  passing  through  the  posterior  chamber, 
after  penetrating  the  coats  of  the  eye,  and  being  then  plunged 
into  the  lens  through  the  anterior  capsule,  it  generally  enters 
the  cataract  directly  it  has  punctured  the  membranes,  slightly 
lacerating  in  its  course  the  hyaloid  membrane  and  the  vitreous 
humor.  This  is  a  point  of  practical  importance,  for  if  the  point 
of  the  instrument  in  this  case  be  turned  backward,  as  for  rup- 
turing the  capsule,  it  becomes  more  deeply  imbedded  in  the 
cataract,  and  the  anterior  capsule  is  then  liable  to  remain  unin- 
jured when  the  lens  is  depressed.  When,  therefore,  the  needle 
is  not  distinctly  seen  in  the  posterior  chamber  before  the  de- 
»n  is  commenced,  its  point  should  be  turned  forward 
towards  the  cornea  to  break  up  the  anterior  capsule.  After 
which  it  is  again  directed  upon  the  cataract  to  depress  it,  this 
accident  is  particularly  liable  to  happen  in  pure  lenticular  cata- 
ract, and  if  the  anterior  capsule  have  not  been  broken,  a  sec- 
ondary capsular  cataract  is  the  consequence. 

If  the  cataract  have  been  soft,  the  aqueous  humor  will  be 
rendered  turbid,  and  portions  of  the  lens  will  enter  the  anterior 
chamber.     This  circumstance  as  it  prevents  immediate  vision, 


may  cause  some  disappointment ;    but   these  parts  are  soon 
absorbed,  and  the  humor  again  rendered  transparent. 

The  Anterior  Operation  is  seldom  employed  for  depression, 
It  is  chiefly  confined  to  the  operation  by  absorption  ;  and,  for 
the  most  part,  to  the  congenital  cataract.  It  is  much  more 
simple  than  the  former,  and  consists  in  introducing  the  straight 
needle  through  the  cornea  and  pupil  into  the  cataract,  whence, 
after  being  freely  moved  about  to  lacerate  the  capsule  and  lens, 
it  is  immediately  withdrawn.  The  chief  precautions  to  be  ob- 
served, are  to  present  the  needle  perpendicularly  to  the  cornea, 
or  it  may  pass  between  its  lamina  and  fail  to  enter  the  eye : 
and,  secondly,  to  avoid  running  the  needle  through  the  iris. 
This  is  often  very  difficult  on  account  of  the  involuntary 
and  forcible  action  of  the  globe,  by  which  the  needle  is  diverted 
from  its  course.  In  operating  upon  children,  they  should  al- 
ways be  laid  on  a  table,  and  be  firmly  secured  by  assistants. 
The  surgeon  sits  at  the  head  of  the  table,  or  by  the  side  of  the 
patient,  as  suits  his  convenience.  The  same  directions  in  re- 
gard to  the  preliminary  arrangements,  and  subsequent  manage- 
ment apply  to  all  the  operations. 

Operation  by  Absorption. — The  mode  of  proceeding  in  this 
operation,  is  the  same  in  every  respect  as  that  for  depression, 
except  that  the  cataract  is  not  removed  from  its  natural  situa- 
tion. The  anterior,  or  the  posterior  operation  may  alike  be 
employed.  The  needle  is  introduced  into  the  cataract,  and 
then  freely  moved  about  to  break  it  down.  The  congenital 
cataract  is,  however,  generally  and  most  properly  treated  by 
the  anterior  method.  This  operation  was  proposed  by  Messrs. 
Hey  and  Pott,  from  having  observed  that  when  portions  of 
opaque  matter  obtained  access  to  the  aqueous  humor,  they  soon 
disappeared,  and  the  pupil  became  clear.  It  was  hence  sup- 
posed that  the  aqueous  humor  dissolved  the  cataract,  but  this 
has  been  disproved ;  and,  it  is  now  only  known,  that  the  ad- 
mission of  the  aqueous  humor  to  the  cataract  promotes  its  ab- 
sorption. The  object  of  the  operation,  therefore,  is  to  admit 
this  humor  to  the  cataract,  exposed  to  its  action  by  as  much  of 


49 

its  surface  as  possible.  The  operator  may  push  some  portions 
of  the  broken  cataract  into  the  anterior  chamber  with  advan- 
tage. There  is  less  danger  of  subsequent  inflammation  by  this 
process  than  by  any  of  the  others  ;  for  less  injury  is  inflicted 
upon  the  tunics  of  the  eye.  It  is  not  applicable  to  hard  cata- 
racts, on  account  of  the  difficulty  in  dividing  them,  and  the 
slowness  with  which  they  are  absorbed.  The  chief  inconve- 
nience of  the  operation  is,  that  in  consequence  of  incomplete  ab- 
sorption in  some  cases,  a  second  becomes  necessary.  It  is  for- 
tunate, however,  in  this  respect,  that  the  eye  can  bear  two  or 
three  operations  as  well  as  one. 

The  return  of  the  cataract  to  its  original  place  in  the  axis 
of  vision  is  an  occurrence  which  sometimes  happens.  It  may 
take  place  a  few  days  after  the  operation ;  or,  as  has  in  a  few 
instances  been  known,  after  the  lapse  of  several  years.  In  the 
former  case  a  second  operation  is  necessaiy  when  the  effects 
of  the  first  have  been  removed.  The  operation  of  extraction 
might  be  performed  in  either  instance  ;  but  in  the  latter,  it  is  the 
most  advisable. 

Operation  by  Extraction. — The  intention  in  this  operation 
is  to  get  rid  of  the  cataract  by  removing  it  from  the  eye 
through  the  cornea.  Extraction  is  decidedly  the  most  difficult 
mode  of  operating,  from  the  precision  and  accuracy  with  which 
it  is  necessary  to  manage  the  instrument,  and  the  accidents 
which  constantly  threaten  to  thwart  its  success,  and  sometimes 
even  its  completion.  It  is  performed  with  a  knife,  first  used  by 
Mr.  Barth  of  Vienna,  but  known  as  Beer's  knife.  The  inten- 
tions to  be  fulfilled  by  the  instrument,  are  first  to  puncture  the 
cornea,  for  which  purpose  it  has  a  lancet-shaped  point;  sec- 
ondly, to  make  a  section  of  the  cornea,  and  it  therefore  has  one 
long  cutting  edge  ;  thirdly,  to  fill  entirely,  during  the  execution 
of  these  objects,  the  incision  it  makes,  until  the  whole  section  be 
completed.  The  shape  of  the  knife  is,  therefore,  triangular,  the 
apex  being  the  point,  and  the  longest  side  the  cutting  edge. 
The  necessity  that  the  incision  should  be  constantly  filled  by 
the  knife,  is  that  the  aqueous  humor  may  not  escape.     The 

7 


50 

occurrence  of  which  circumstance  causes  the  cornea  to  become 
flaccid,  and  consequently  to  receive  an  irregular  or  jagged  sec- 
tion. The  knife  should,  therefore,  not  only  gradually  increase 
in  breadth,  but  also  in  thickness.  The  whole  blade  is  eighteen 
lines  in  length.  The  instrument  is  to  be  taken  in  the  hand,  and 
managed  in  the  same  manner  as  the  needle  is  in  depression. 
The  mode  of  conducting  the  operation  is  as  follows  : — 
The  point  of  the  instrument  is  presented  perpendicularly  to 
the  cornea,  a  short  distance  below  its  horizontal  diameter,  and 
abou  a  line  from  its  outer  margin ;  the  flat  side  of  the  knife 
being  in  the  vertical  plane  of  the  eye.  The  cornea  is  then 
punctured,  and  immediately  the  knife  is  turned  in  such  a  man- 
ner, that  the  point  enters  the  anterior  chamber  parallel  with  the 
surface  of  the  iris.  The  knife  is  then  passed  steadily,  and  as 
rapidly  as  is  consistent  with  safety,  through  the  anterior  cham- 
ber, until  the  point  reaches  the  cornea  on  the  inner  side  of  the 
globe.  In  this  course,  the  surgeon's  eye  should  be  constantly 
fixed  on  the  point  of  the  instrument,  to  see  that  it  does  not 
touch  the  iris.  Having  reached  the  internal  surface  of  the  cor- 
nea on  the  inner  side,  the  knife  is  firmly  forced  through,  and  is 
then  carried  forward  towards  the  nose  until  it  cuts  itself  out 
with  a  clean,  smooth  incision.  If  the  blade  prove  not  long 
enough,  a  steady  back  stroke  is  made  to  finish  the  section.  Es- 
pecial care  is  here  requisite  to  keep  the  side  of  the  knife  paral- 
lel with  the  iris,  or  it  may  turn  inward  and  cut  the  sclerotica  ; 
or  outward,  and  emerge  too  near  the  horizontal  diameter  of  the 
cornea.  The  section  of  the  cornea  being  made,  a  delicate  hook, 
or  curved  needle  is  introduced  under  the  flap,  with  its  convexity 
turned  upward,  and  passed  through  the  pupil  to  lacerate  the 
capsule  by  two  free  strokes  made  at  right  angles.  The  cata- 
ract is  then  seized  with  the  instrument  and  withdrawn  through 
the  section.  Tnis  part  of  the  operation  sometimes  demands 
great  caution,  for  a  large  cataract  does  not  readily  pass  through 
the  pupil.  When  the  extraction  is  made  slowly,  the  pupil  gradu- 
ally expands,  and  suffers  the  cataract  to  pass,  though  it  some- 
times appears  that  the  iris  is  about  to  be  torn  from  its  attach- 


51 

menls.     The  moment  the  extraction  is  completed,  the  assistant 
allows  the  lid  to  fall. 

During  the  several  processes  a  number  of  accidents 
may  befall  the  operator.  Thus,  if  the  knife  be  not  placed 
perpendicularly  upon  the  cornea,  it  may  pass  between  its 
lamina  and  fail  to  make  the  required  incision.  The  puncture 
of  the  cornea  may  be  followed  by  the  escape  of  the  aque- 
ous humor,  by  which  means  the  cornea  loses  its  convexity  and 
is  liable  to  receive  a  rough  incision.  The  iris  likewise,  being 
deprived  of  its  support,  may  fall  forward  and  be  wounded. 
When  the  escape  of  the  aqueous  humor  produces  these  changes 
in  the  situation  of  the  cornea  and  iris,  to  guide  the  knife  between 
them  is  a  delicate  task,  and  the  surgeon  is  involved  in  the  most 
difficult  part  of  the  operation.  If  the  iris  fall  before  the  knife, 
the  instrument  must  be  withdrawn.  Sometimes  stimulating  the 
iris  by  allowing  the  lid  to  fall  while  the  surgeon  keeps  the  knife 
at  rest,  and  then  quickly  opening  it  again,  causes  a  contraction 
which  liberates  it  from  before  the  edge  of  the  instrument.  The 
same  object  is  sometimes  attained  by  gently  rubbing  the  globe 
of  the  eye  with  the  finger  nail,  or  the  handle  of  a  cataract  nee- 
dle. Again,  when  the  second  puncture  of  the  cornea  is  to  be 
made,  the  pressure  of  the  knife  may  force  the  globe  inward 
by  which  means  the  puncture  may  not  be  formed  sufficiently 
near  the  inner  margin  of  the  cornea  to  afford  an  ample  incision. 
The  corneal  section  may  be  followed  by  prolapsus  iridis,  which 
must  be  returned  before  the  operation  can  proceed.  If  the  lid 
be  allowed  to  fall  and  remain  a  few  moments  over  the  eye,  and 
be  then  quickly  opened  towards  a  strong  light,  the  natural 
action  of  the  iris  may  restore  it  to  its  place.  If  this  fail  it  must 
be  returned  by  means  of  a  curette  ;  and,  finally,  when  the  cata- 
ract is  withdraw!:,  prolapsus  iridis  may  again  occur,  or  the 
\iii' miis  humor  may  escape.  The  prolapsus  must  be  returned 
in  the  same  manner  as  before.  Loss  of  the  vitreous  humor  is 
of  but  little  consequence*  It  is  quickly  reformed,  and  vision 
do<  -  not  suffer.  To  prevent  these  accidents  the  precautions 
given  should  be  carefully  followed;  the  patient  should  be  ope- 


52 

rated  upon  lying  on  his  back,  to  prevent  as  far  as  possible  the 
escape  of  the  vitreous  humor  ;  and,  if  this  do  happen,  to  allow 
the  iris  to  fall  backward ;  the  assistant  should  avoid  pressing  the 
globe  ;  and  the  surgeon  should  have  practised  the  operation  as 
far  as  possible  on  the  dead  eye,  and  then  operate  with  firmness 
and  presence  of  mind. 

Baron  Wenzel,  is  stated  to  have  said,  that  "before  he 
learned  to  extract,  he  had  destroyed  a  hat  full  of  eyes :"  and, 
from  the  reports  of  some  of  the  present  French  surgeons,  it 
would  appear  that  they  use  still  larger  measures.  The  dangers 
of  the  operation,  together  with  the  greater  liability  to  future 
inflammation,  are  considered  just  reasons  for  the  preference 
given  to  depression. 

When  extraction  is  performed,  it  is  generally  selected  for 
hard  cataracts,  though  any,  but  such  as  are  very  soft,  may  be 
thus  removed.  In  traumatic  cataract,  where  the  lens  has  en- 
tered the  anterior  chamber,  it  is  most  advantageously  employed. 
When  the  lens  is  in  this  situation,  it  usually  follows  the  removal 
of  the  knife,  and  the  operation  is  then  finished.  Sometimes 
from  the  collapse  of  the  cornea,  it  returns  to  the  posterior 
chamber,  and  must  then  be  extracted  by  the  hook,  or  by  gentle 
pressure  on  the  globe.  It  has,  also,  been  known  to  escape  into  the 
vitreous  humor,  out  of  the  axis  of  vision,  and  be  then  absorbed. 
If  secondary  capsular  cataract  follow,  it  may  be  removed  by 
the  operation  of  absorption. 

The  second  mode  of  operating  by  extraction,  is  performed  in 
the  same  manner  as  the  former,  except  that  the  section  is  made 
in  the  superior  instead  of  the  inferior  part  of  the  cornea.  It  is 
most  highly  recommended  by  Graefe  of  Berlin,  who  reports  the 
cure  of  seventeen  out  of  eighteen  cases  by  this  operation.  The 
advantages  he  attributes  to  it  are,  that  the  aqueous  humor  is  less 
liable  to  escape  ;  and  that  prolapsus  iridis  takes  place  with 
greater  difficulty. 

3.  Treatment  after  the  operation. — Within  six  hours  after 
the  operation  on  a  cataract,  the  eye  should  be  examined,  and 
active  treatment  be  commenced,  if  the  least  unfavorable  symp» 


53 

torn  exist.  The  indication  of  treatment  is  to  prevent  the  occur- 
rence of  inflammation  ;  and  not  to  subdue  it  when  it  has  once 
commenced.  All  the  parts  wounded  in  the  operation  by  depres- 
sion are  subject  to  subsequent  inflammation,  but  its  most  frequent 
seat  is  the  iris.  If  disease  in  these  cases  be  not  checked  by 
energetic  management,  it  proceeds  to  a  destructive  extent. 
Severe  iritis,  together  with  external  ophthalmia,  may  be  con- 
joined with  amaurosis  or  glaucoma,  giving  rise  to  niuch  suffer- 
ing, and  perhaps  the  loss  of  the  eye.  If,  then,  at  the  first  exami- 
nation any  pain  be  present  in  the  head,  or  eye,  or  any  evidence  of 
commencing  inflammation  be  detected,  blood  should  immediately 
be  taken  from  the  arm.  If  the  symptoms  be  very  trivial,  the 
application  of  cups  to  the  temple,  together  with  an  active  ca- 
thartic will  suffice.  When,  however,  they  manifest  any  sever- 
ity, venesection  should  at  once  be  resorted  to.  With  this,  anti- 
monial  solution ;  or  magnes  :  sulph :  with  antimon  :  tartr  :  may 
be  prescribed,  as  the  case  may  require. 

The  following  formula  possesses  great  power  in  reducing 
acute  external  inflammation  of  the  eye,  as  of  the  conjunctiva 
and  cornea. 

Yjc.  Magnes  :  Sulph :     §  ii. 
Antimon :  Tartr  :    gr.  iii. 
Aq :  Purae  §  xvi.     M. 

Of  this  §ii  may  be  taken  every  hour  until  an  emetic  and 
cathartic  effect  are  produced.  It  should  be  then  discontinued  ; 
and  be  repeated  the  first  or  second  day  afterwards  as  occasion 
may  demand.  With  this,  fomentation  of  the  eye  with  warm 
water,  or  the  lot :  opii  should  be  conjoined.  This  remedy 
is  much  less  effectual  in  iritic  inflammation,  or  any  form  of  in. 
ternal  ophthalmia. 

In  very  severe  iritis  it  is  necessary  to  obtain  the  constitu- 
tional effects  of  mercury  in  the  most  speedy  manner.     For  this 
purpose  the  combination  of  calomel  and  pulv:  antimon: 
fy.  Calomel :  gr.  ii. 

Pulv:  Antimon:  gr.  iii.     M. 
Fit  in  pi]. 


54 

may  be  prescribed  every  third  or  fourth  hour.  When  the 
symptoms  are  less  acute,  the  mercury  may  be  introduced  into 
the  system  more  gradually.  Under  this  treatment  the  inflam- 
mation seldom  fails  to  subside. 

The  temperature  of  the  patient's  apartment  should  not  be 
disregarded,  for  exposure  to  cold  is  sufficient  to  thwart  the 
most  active,  and  well-directed  remedies. 

A  long  course  of  treatment  of  a  general  antiphlogistic  char- 
acter sometimes  induces  a  state  of  debility  in  which  the  inflam- 
mation remains  obstinately  stationary,  or  becomes  worse  ;  re- 
course, in  this  state,  to  a  tonic  regimen,  often  produces  a  decided 
improvement. 

The  occurrence  of  glaucoma,  or  amaurosis  after  the  opera- 
tion, may  be  removed  by  the  same  remedies  employed  for  iritis. 
The  actual  existence  of  iritic  inflammation  must  be  overcome 
by  the  use  of  mercury  in  small,  often-repeated  doses,  until  it 
affects  the  system  sufficiently  to  control  the  disease.  The  ac- 
tion of  mercury  requires  also  the  aid  of  frequent  cupping,  the 
application  of  blisters,  and  strict  attention  to  diet.  If  either  of 
these  affections  continue  with  unusual  obstinacy,  as  sometimes 
occurs,  the  application  of  blisters  requires  some  management- 
One  may  be  applied  over  the  eyebrow  ;  and,  when  after  four  or 
five  days  it  has  healed,  another  may  be  put  behind  the  ear ;  a 
third  may  be  placed  on  the  nape  of  the  neck  ;  and  thus  a  suc- 
cession may  be  used,  if  necessary,  at  intervals  of  a  few  days. 
This  course  obviates  the  necessity  of  applying  a  new  blister  to 
an  already  inflamed  surface,  and  yet  maintains  an  active  and 
constant  counter-irritation. 

cThe  conjunctival  inflammation  which  follows'an  operation  is 
sometimes  accompanied  with  chemosis.  This  effusion  is,  how- 
ever, absorbed  as  the  inflammation  is  subdued.  It  does  not 
require  that  the  conjunctiva  should  be  punctured,  unless  its 
distention  be  very  great,  and  threaten  to  rupture  the  mem- 
brane. 

Contraction  of  the  pupil  may  occur  as  the  sequel  of  iritis. 


55 

In  this  case,  an  operation  to  form  an  artificial  pupil  will  be 
necessary. 

Prolapsus  iridis  occasionally  happens  a  short  time  after  the 
operation  of  extraction,  exciting  inflammation,  and  causing  an 
adhesion  to  it  of  the  edges  of  the  cornea.  In  addition  to  the 
general  treatment  for  the  inflammation,  it  will  be  necessary 
either  to  cut  oflf  the  prolapsed  portion  of  iris,  with  a  curved 
scissors,  or  to  touch  it  with  the  argentum  nitratum. 

The  surgeon  should  be  careful  to  examine  the  eye  within  a 
short  time  after  an  operation  of  extraction,  to  ascertain  if  the 
edges  of  the  corneal  incision  be  precisely  in  coaptation.  They 
sometimes  become  so  separated  that  the  inner  edge  of  one  flap 
unites  to  the  external  edge  of  the  incised  surface  on  the  other. 
This  circumstance  creates  additional  irritation  in  the  wound, 
protracts  the  process  of  adhesion,  causes  a  greater  deposition  of 
fibrin,  and  consequently  a  larger  cicatrice. 

Vomiting,  which  may  happen  after  an  operation,  is  always 
a  dangerous  occurrence.  From  the  violent  agitation  of  the 
head  which  it  causes,  the  depressed  cataract  may  again  rise  to 
the  axis  of  vision,  while  the  cerebral  congestion  it  occasions,  is 
liable  to  induce  inflammation.  It  is  chiefly  incident  to  old  per- 
sons who  have  led  an  intemperate  life  ;  and,  if  its  occurrence 
could  be  correctly  foretold,  would  forbid  an  operation.  The 
vomiting  must  be  allayed  by  narcotics,  or  such  remedies  as  the 
state  of  the  stomach  indicates. 

When  no  untoward  symptoms  appear,  the  patient  should  be 
kept  for  a  few  days  in  a  darkened  room ;  a  shade  should  be 
kept  before  the  eye  to  prevent  any  sudden  admission  of  light ; 
his  regimen  should  be  of  the  mildest  character  ;  and  the  occa- 
sional use  of  an  aperient  should  be  resorted  to.  This  cautious 
system  should  he  continued  for  a  couple  of  weeks,  or  until  the 
wounds  in  the  eye  have  entirely  united,  and  all  preternatural 
excitemenl  of  the  organ  has  subsided.  The  person  may  then 
gradually  return  to  his  usual  exercise,  and  diet.  Several  months 
should   elapse  before   the  "'ye  is  in  any  manner  tasked. 

Afj  now,  the  natural  refracting  lens  of  the  eye  has  been  re- 


56 

moved,  its  place  must  be  supplied  by  one  which  is  artificial 
A  double  convex  glass,  adapted  to  the  patient's  vision  should 
be  procured,  and  be  constantly  worn.  Two  glasses  of  different 
powers  are  generally  required ;  one  adjusted  for  distant  objects, 
and  one  for  subjects  requiring  minute  inspection.  The  use  of 
the  glass  must  not  be  commenced  until  every  trace  of  irri- 
tation be  removed,  and  the  eye  have  regained  its  natural  tonic 
condition.  In  regard  to  the  selection  of  glasses,  particular 
directions  cannot  be  given.  The  eye  must  be  tried  with  sev- 
eral of  different  power ;  and  that  chosen  which  enables  the 
patient  to  see  most  distinctly,  without  occasioning  any  sense  of 
straining,  or  smarting  in  the  eye.  The  glasses  which  most  fre- 
quently suit  the  eye-fbr  reading,  are  those  which  have  a  focus 
of  two  or  three  inches.  The  focal  distances  of  glasses  for  gen- 
eral use  vary,  in  most  instances,  between  three  and  a  half,  and 
five  inches. 

Having  thus  fulfilled,  though  indifferently,  the  requisition  of 
the  college,  it  only  remains  for  me  to  thank  the  professors  for 
the  instruction  I  have  derived  from  their  knowledge ;  and  to 
assure  them,  that  the  hopes  they  have  expressed  for  the  future 
success  of  the  graduate,  are  reciprocated  in  a  sincere  wish  for 
their  continued  prosperity. 


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